Specialist Interagency Teams


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, incontinence, vision and hearing, cognition, end of life and dementia care.

Comprehensive geriatric assessment (CGA) is a multidimensional, interdisciplinary (usually) process to understand a person’s needs to be able to develop a holistic plan for treatment, rehabilitation, support and long term follow up.

Case management is a way of coordinating care around a person with long-term conditions and complex needs, normally used for those at risk of adverse outcome such as hospital admissions. It should be targeted, community-based and pro-active.

The following are examples of what to consider when thinking about supporting people with multimorbidity and increasing complex care needs (implementation and delivery will vary depending on local circumstances and care pathways. It is likely that with increasingly needs a person will be referred to a specialist interagency team for a CGA and onwards case management):


  • Proactive comprehensive geriatric assessment (CGA) [general practice/community-based] and follow-up for people identified as moderately or severely frail, with a specific focus as part of CGA on medication review and falls assessment – see below.
  • 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.
  • A multi-disciplinary care team led by clinician, usually a GP, wraps around the patient and is responsible for the patient from pre-admission, during admission and post admission.
  • The case manager or MDT designs the care plan with the patient and carer (informed decisions), if appropriate. The care plan is shared with providers 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 people with dementia and mental health problems must be available and accessible.
  • A comprehensive service for those with palliative care needs must be available and accessible
    • Identification through GP lists
    • Tools are used systematically to identify frail older people at the end of their life
    • IT systems support coordination
    • Advance care planning is not seen as a one-off event
    • Equitable access to specialist palliative care services
  • Services are available to reduce polypharmacy in frail older people.
  • For those people living in care homes, implementation of the Enhanced Health in Care Homes (EHCH) framework should be considered.



Nutrition and Hydration


Bowel and bladder care


Sight and hearing


Cognition and Dementia Care


End of Life Care


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