The Impact of Domiciliary Versus 'Hub' Based Comprehensive Geriatric Assessment on Clinical and Process Outcomes Among Older Adults Attending Community Specialist Teams: a Randomised Controlled Trial.

Overview

The investigators plan to implement a randomised controlled trial to examine the impact of domiciliary (home based) versus 'hub-based' Comprehensive Geriatric Assessment (CGA) on clinical and process outcomes among older adults referred to a community specialist team for older persons in the Mid-West region of Ireland. The population of interest is older adults who are discharged directly from the Emergency Department or referred urgently from their General Practitioner. The outcomes of interest focus on those that matter most to older adults as well as clinical and process measures of care.

CGA is defined as a "multidimensional interdisciplinary diagnostic process focused on determining a frail elderly person's medical, psychological and functional capability in order to develop a coordinated and integrated plan for treatment and long term follow up" (1). The CST hub in Limerick provides a rapid, single point of access to an outpatient specialist geriatrician and allied health professional assessment. The bulk of this therapy is delivered in each of the hubs. This is considered 'usual' or routine care for the purposes of this trial. The intervention will consist of domiciliary multidisciplinary CGA and intervention including nursing, medical and allied health assessment and intervention for frail older adults over age 75 who are discharged from the ED, or referred urgently from their General Practitioner and referred to the CST in Limerick. The bulk of this intervention will be delivered in the patient's own home. Each participant will be required to attend the hub for their medical review where they will access specialist geriatric medical expertise. A domiciliary visit to the older person within 24-48 hours of referral from the ED or within 24-48 hours of triage of GP referral by a member of the multidisciplinary team will be carried out. This person will act as the case coordinator for the duration of the intervention. During this visit, there will be a detailed assessment of the older adult. The assessment will include but not be limited to a falls assessment, assessment of mobility and stairs, transfer, personal care, activities of daily living (ADLs), social supports, cognition, lying \& standing blood pressures and nutritional assessment. Referrals will be made for domiciliary care to the appropriate healthcare professionals (nursing, OT, physiotherapy, dietetics etc) based on the findings of this holistic assessment. Interventions prescribed will be individualised based on patient needs. The investigators will use the template proposed by Ellis et al. (2017) to characterise the components of the CGA intervention. The trial will assess the benefits of this domiciliary model of care on outcomes including the following: function, quality of life, patient satisfaction, primary and secondary healthcare use, nursing home admission, mortality and cost-effectiveness. Baseline measurement will be taken at their index visit with follow-up at six weeks and 6 months.