Comprehensive geriatric assessment [CGA] and case management

Access to specialist interagency teams for a comprehensive geriatric assessment [CGA] and case management including the development of an emergency health care plan to coordinate care and optimise nutrition and hydration, bowel and bladder care, vision and hearing, cognition and dementia care, and end of life.

What works

  • Proactive comprehensive geriatric assessment (CGA) [general practice/community-based] and follow-up for people identified as moderately or severely frail (in line Anticipatory Planning Model in PCN contract).
  • An identified keyworker who acts as a case manager and coordinator of care across the system – community, primary and inpatient hospital care.
  • Case management delivered through integrated locality-based teams (access to community geriatrics).
  • The case manager or MDT designs the care plan with the person and carer (informed decisions), if appropriate. The care plan is shared  across the system and implemented by MDTs and updated appropriately (e.g. in response to a crisis).
  • Carers are offered an independent assessment of their needs and signposted to interventions to support them in their caring role.
  • A comprehensive service for those with palliative care needs must be available and accessible (via GP lists, not one-off, access to specialist teams)
  • For those people living in care homes, implementation of the Enhanced Health in Care Homes (EHCH) framework should be considered (In line with PCN contract).

  • Reduces mortality and improves independence after admission to hospital
  • Reverses the progression of frailty
  • Reduces nursing home admission
  • Improves functioning (for home- and community-based occupational therapy)
  • Likely to die in preferred place of death (6 times more likely, including improve quality and pain relief in last stages of life)
  • Reduces emergency, inpatient admissions and occupied bed days
  • Improves patient and family satisfaction with care

Evidence Summaries

Impact and Measures

We know that  frailty has a significant impact of people, populations and health and care systems. Frail older people are highly susceptible to adverse health outcomes, such as falls, disabilities, institutionalisation, hospitalisation and death. However, trying to understand this impact on populations and health and care system is challenging due to poor recording of frailty status and the lack of information sharing and interoperability that exists. The following examples of impact are guestimates based on current intelligence.


  • Potential Impact
  • Potential measures
    • People aged 65 years and over with moderate or severe frailty who are recorded as having had a fall in the preceding 12 months
    • People aged 65 years and over, with depression or dementia, and who have moderate or severe frailty
    • Measurement of loneliness / reduced loneliness
    • The proportion of people (aged 65+ years) who use services who have control over their daily life
    • A&E attendance rates for patients aged 65 years and over
    • Emergency hospital admission rates for patients aged 65 and over


For more information to aid local delivery see what works, resource links, benefits, evidence, local stories and case studies as well as impact/measures in ‘word version of draft frailty toolkit’ page 68