Target population

The two target population groups for the ‘assessment visit’ intervention in this project were:

  1. All people aged over 85 years and all people of any age diagnosed with dementia and / or know to be housebound. This cohort were automatically offered an assessment visit.
  2. All people in the age range 75-84 years were sent the Tilburg questionnaire (a self-report screening questionnaire) by post, along with information about local services for older people. People who scored a high risk score for frailty on the returned questionnaires were offered the same assessment visit as that offered to the first group.

The project did not include people living in nursing homes, as their specific needs were already being addressed through enhanced primary care services for nursing home residents commissioned by the CGG.

From case finding to action

The first step in the assessment process was the identification of older people eligible for a visit directly from the practice’s registered population in the case of people aged over 85 years, or from the registered population after the screening questionnaire for people aged 75-84 years. The individual older people were contacted by telephone to make the initial arrangements for the assessment visit ideally with the Next of Kin also able to be present, followed up by confirmation in writing.

The ‘assessment visit’ itself was carried out by an Elderly Care Facilitator (ECF) during which the ECF carried out a holistic older person’s assessment. A comprehensive assessment checklist and visit pack was used to complete this structured assessment, which identified problems and risk factors for which the person might benefit from further support.

This assessment was completed and recorded through a series of structured templates and ideally took place with a relative, carer or friend of the older person present. As a result of the assessments, action plans were drawn up and further support offered through a very wide range of voluntary, public sector, community, health and care services. Any suggested action points were agreed with the older person and the person they had chosen to support them before the end of the visit.

After completion of the visits, the results of the assessments were entered into the electronic patient record through a series of clinically coded templates. Any necessary referrals were made and feedback to the GP took place when indicated. Finally a letter was written to the patient summarising the action points arising from the visit and assessment.

The project took a very flexible approach to resource deployment. Various combinations of practice coordinator, practice nurse or care worker took on the responsibility of organizing the questionnaires, assessment visits and action plans across the different practices involved. However, the common feature across all practices was that GPs only became involved in the process on a case-by-case basis, if there was a specific need for medical referral.

To read the full project report click here