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.

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.

Inclusion criteria

• Referred to the CST hub from a General Practitioner (urgent referral) or from the ED at University Hospital Limerick.

All of criteria 1-5 must be met

• 75 years and over
• Evidence of frailty, scoring between 4 and 6 on the Rockwood Clinical Frailty Scale (pre-frail, mildly frail or moderately frail)
• Resides within CHO 3 and the catchment area of the relevant ICPOP hub
• Patient has been assessed in-person by the referrer
• Patient has not had MDT input within the last three months (excluding OPTIMEND team)

And any one of criteria 6-10 must be met:

• Fall within the last month unrelated to acute cardiac or neurological cause & no previous falls assessment
• Increased dependency or increased carer burden in the last month
• A deterioration in swallow in the last month including symptoms of recurrent chest infections, weight loss, coughing when eating/drinking, self-modifying diet secondary to difficulties
• Adverse drug reaction within the last month excluding allergic reaction Referred from ED/AMU following review by consultant in Emergency Medicine, Acute Medicine, Geriatric Medicine, General Medicine or Frailty at the Front Door team

Exclusion criteria

• Present with an acute neurological or cardiovascular event
• Are more appropriate to an alternative care pathway or service e.g. primary care or geriatric medicine clinic
• Present with injuries, unless the injury has already been appropriately managed,
• Are experiencing an acute medical illness requiring treatment in an acute hospital setting
• If care is being provided by other health care professionals at the time of referral and it is apparent that they are working to meet goals aligned with the current service
• They require investigation or treatment not available in the relevant ICPOP hub (unless these investigations are already being arranged elsewhere)
• They have had MDT input in the last three months
• Have confirmed or suspected Covid-19 infection
• Or other exclusions at the discretion of the integrated care team based on clinical expertise and available resource.