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For peer review only
The Role of Comprehensive Geriatric Assessment in
Healthcare of Older People in UK Care Homes: realist review
Journal:
BMJ Open
Manuscript ID
bmjopen-2018-026921.R1
Article Type:
Research
Date Submitted by the
Author:
18-Jan-2019
Complete List of Authors:
Chadborn, Neil; University of Nottingham, School of Medicine, Division of
Rehabilitation and Ageing; National Institute of Health Research
Collaboration for Leadership in Applied Health Research and Care East
Midlands
Goodman, Claire; University of Hertfordshire, Centre for Research in
Public Health and Community Care ; National Institute of Health
Research Collaboration for Leadership in Applied Health Research and
Care East of England
Zubair, Maria; University of Sheffield, Interdisciplinary Centre of the
Social Sciences
Sousa , Lídia; Santa Maria University Hospital
Gladman, John; University of Nottingham, Rehabilitation and Ageing;
National Institute of Health Research Collaboration for Leadership in
Applied Health Research and Care East Midlands, Nottingham
Dening, Tom; University of Nottingham, School of Medicine, Division of
Psychiatry and Applied Psychology
Gordon, Adam; University of Nottingham, School of Medicine, Division of
Medical Science and Graduate Entry Medicine; National Institute of
Health Research Collaboration for Leadership in Applied Health Research
and Care East Midlands, Nottingham
<b>Primary Subject
Heading</b>:
Geriatric medicine
Secondary Subject Heading:
General practice / Family practice, Health services research, Nursing,
Occupational and environmental medicine, Patient-centred medicine
Keywords:
comprehensive geriatric assessment, care homes, multidisciplinary, care
planning, Quality in health care < HEALTH SERVICES ADMINISTRATION
& MANAGEMENT, GERIATRIC MEDICINE
For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml
BMJ Open
For peer review only
The Role of Comprehensive Geriatric Assessment in Healthcare of
Older People in UK Care Homes: realist review
Neil H Chadborn (1,2), Claire Goodman (3,4), Maria Zubair (5), Lídia Sousa (6), John RF Gladman (1,
2,8), Tom Dening (9), Adam L Gordon (2,7,8,10).
1. Division of Rehabilitation and Ageing, School of Medicine, University of Nottingham, UK, School of
Medicine, University of Nottingham, UK
2. National Institute of Health Research Collaboration for Leadership in Applied Health Research and
Care East Midlands, Nottingham, UK.
3. Centre for Research in Public health and Community Care, University of Hertfordshire,
Hertfordshire, UK
4. National Institute of Health Research Collaboration for Leadership in Applied Health Research and
Care East of England, UK
5. Interdisciplinary Centre of the Social Sciences, University of Sheffield, UK
6. Santa Maria University Hospital, Lisbon, Portugal
7. Division of Medical Sciences and Graduate Entry Medicine, School of Medicine, University of
Nottingham, UK
8. Nottingham Biomedical Research Centre, University of Nottingham, UK
9. Division of Psychiatry and Applied Psychology, School of Medicine, University of Nottingham
10. School of Health Sciences, City, University of London, UK
Corresponding author email address
neil.chadborn@nottingham.ac.uk
Abstract
Objectives
Comprehensive Geriatric Assessment (CGA) may be a way to deliver optimal care for care home
residents. We used realist review to develop a theory-driven account of how CGA works in care
homes.
Design
Realist review
Setting
Care homes
Methods
The review had three stages: first, interviews with expert stakeholders and scoping of the literature
to develop programme theories for CGA ; second, iterative searches with structured retrieval and
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extraction of the literature; third, synthesis to refine the programme theory of how CGA works in
care homes.
We used the following databases: Medline, CINAHL, Scopus, PsychInfo, Pubmed, Google Scholar,
Greylit, Cochrane Library, and Joanna Briggs Institute.
Results
130 articles informed a programme theory which suggested CGA had three main components:
structured comprehensive assessment, developing a care plan, and working towards patient-centred
goals. Each of these required engagement of a multi-disciplinary team (MDT). Most evidence was
available around assessment, with tension between structured assessment led by a single
professional and less structured assessment involving multiple members of an MDT. Care planning
needed to accommodate visiting clinicians and there was evidence that a core MDT often used care-
planning as a mechanism to seek external specialist support. Goal-setting processes were not always
sufficiently patient-centred and did not always accommodate the views of care home staff. Studies
reported improved outcomes from CGA affecting resident satisfaction, prescribing, healthcare
resource use and objective measures of quality of care.
Conclusion
The programme theory described here provides a framework for understanding how CGA could be
effective in care homes. It will be of use to teams developing, implementing or auditing CGA in care
homes. All three components are required to make CGA work – this may explain why attempts to
implement CGA by interventions focussed solely on assessment or care planning have failed in some
long-term care settings.
Registration details
PROSPERO (PROSPERO 2017:CRD42017062601).
Strengths and Limitations of the study
Realist methods enabled us to explore the contextual factors and underpinning causal
mechanisms associated with using CGA in care homes.
The review makes transparent how CGA is thought to work and demonstrates what is
supported by the evidence.
We were limited to the detail included in the studies retrieved, which provided more detail
about assessment than about care planning or management.
Introduction
Around 425,000 people live in care homes in the UK (1). Care homes are classified as either care homes
with, or without, nursing based upon the availability of registered nurses on-site. The types of
residents cared for in both classifications of facility are similar and all UK care homes are included in
the international consensus definition of a nursing home (2). Care home residents are often frail and
characteristically have complex medical histories, multiple morbidities and high levels of functional
dependency (3). UK care homes are primarily institutions that meet the basic and personal care needs
of people with stable disabilities, but rely to varying extents upon external healthcare support to meet
residents’ needs such as symptom control in long-term conditions, end-of-life-care, and the
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consequences of frailty such as delirium and falls. Challenges in meeting their healthcare needs
include variable access to healthcare professionals, inadequate co-ordination of multiple teams
providing care, failure to harness the expertise of care home staff and inappropriate access to
expertise in dementia care (4, 5).
One possible response to these deficiencies has been proposed to be Comprehensive Geriatric
Assessment (CGA)(6). Rubenstein et al defined CGA as a “multidisciplinary diagnostic process intended
to determine a frail older person’s medical, psychosocial, and functional capabilities and limitations in
order to develop an overall plan for treatment and long term follow up” (7). CGA has been shown to
improve outcomes for older people in hospital (8-10) and community settings (11). It encompasses
health and social care needs and facilitates multidisciplinary working. However, evidence regarding its
effectiveness in care homes is limited (12), and there are limited data describing what needs to be in
place for uptake and sustained implementation in this setting.
Although CGA has been identified to have three main components – structured comprehensive
assessment, developing a plan of care, and working towards the delivery of patient-centred goals (13)
– how these components work to achieve improved patient outcomes has not been described. It is
also not clear if CGA works in the same way in care homes as it does in hospital settings, from where
most of the literature derives.
Descriptions of CGA range from solely an assessment process (14), to a model of interprofessional
working and integrated care across health and social care (15). In care homes, national and local policy
shapes how CGA is used. Some countries mandate use of a systematised assessment and care planning
algorithm in the care home sector, with the US Minimum Dataset (MDS)(16) and the widely-used
International Resident Assessment Instrument (InterRAI)(17) being the most frequently cited
examples. There is evidence that these can provide a basis for CGA (18). Very little has been written
about what contextual factors support delivery of CGA in care homes and how CGA operates to
improve standards of care.
Objectives of realist review
This realist review explored the contexts, mechanisms and outcomes which enable CGA to provide a
systematic approach to assessment and care delivery. Realist synthesis methodology was chosen
because it is designed to identify and understand the causal processes and contexts which explain the
outcomes of complex interventions (19). We aimed to provide a theory-driven explanation of how
CGA works in care homes.
To provide a focus for our review, we focussed initially on health-related quality of life (HRQoL), and
satisfaction with, and appropriate use of, health and social care services. These were chosen because
they represented the priorities of service users and providers (20, 21).
The specific objectives of the realist review were:
1. To identify and characterise the elements which make CGA useful as a way of organising
healthcare in care homes, under what circumstances and why.
2. To understand the configuration of different contexts in which CGA is implemented and how
these may act as a resource, or trigger particular mechanisms, to achieve the successful
implementation, uptake and working of CGA in care homes.
3. To seek evidence on the feasibility of using CGA within UK care home settings and its resource
implications and costs.
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Methods
The full protocol for the PEACH realist review has been published elsewhere (22). We have adhered
to the RAMESES guidelines for reporting realist reviews (see Realist And Meta-narrative Evidence
Syntheses: Evolving Standards (23) and Supplementary Appendix 1 for checklist). Databases were
searched initially on 19th May 2017 and finally on 12th July 2018.
A three-stage approach was used (23). Stage one was designed to develop an explanatory model which
would provide an organising framework for the rest of the review. This comprised an initial scoping
review of the literature and also stakeholder interviews to identify possible mechanisms and
outcomes. Search terms and inclusion and exclusion criteria for the review are summarised in the full
published protocol and were chosen to identify literature which used the term “Comprehensive
Geriatric Assessment” (CGA) to describe comprehensive assessment and management of care home
residents. The only deviation from the published protocol was that we did not use the Medical Subject
Heading (MeSH) term “Geriatric Assessment” in Pubmed. This was because we found this term to be
highly inclusive, returning articles on topics ranging from posture and mobility training to
transcutaneous electrical nerve stimulation. We judged that other terms used, including “geriatric
evaluation” and “multidisciplinary geriatric assessment” returned articles much more cogent to the
research question and made it unlikely that we would experience significant omissions by not
including this term.. From an initial reading of the articles retrieved (see Figure 1), four were identified
as providing a particularly detailed articulation of the use of CGA in long-term care (24-27) and
therefore provided a justifiable basis for initial programme theory development. These four articles
were supplemented by semi-structured interviews that focused on how CGA was thought to work and
what needed to be in place for it to achieve the outcomes of interest. Experts were purposively
recruited on the basis of their knowledge of the care home setting and particular professional or
occupational expertise to identify and test the range of assumptions about why and how CGA is
believed to work and why it might be needed for UK care homes.
The data from the papers and interviews were analysed to identify possible configurations of the
circumstances (context), in which clinicians, residents and care home staff respond to using CGA by
changing their reasoning and behaviour (mechanism), which then led to changes in care for the
residents (outcome). These were initially framed as “if… then…” statements, which comprised initial
programme theories of cause and effect.
Stage two involved testing these initial programme theories by revisiting the articles selected from the
initial literature and grey literature searches. We looked for evidence that was relevant to how CGA
was theorised to work in care home settings. Discussions amongst the team considered relevant
evidence (for example, how clinical work is delegated and organised in the care home environment).
Three reviewers (NC, MZ, LS) reviewed and discussed papers using qualitative data analysis software
(NVivo 11) to thematically code according to Context-Mechanism-Outcome (CMO) configurations that
were thought to explain how CGA worked in long-term care settings. Mechanisms were subdivided,
as described by Dalkin (28), into “resource” and “reasoning” components. Resources and reasoning
are mutually constitutive of a mechanism but disaggregating them enables a better understanding of
how resources work within a context, to change individual or group reasoning, to realise an outcome.
As part of this stage, snowball searches – pursuing the references of references – were conducted,
where it was felt likely from the text of the articles that particular articles would further inform the
CMO configurations (29).
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Stage three involved discussion to develop the final iteration of the programme theory, a series of
presentations to the whole project team and to the expert project steering group. The steering group
comprised two lay representatives, two geriatricians, a general practitioner, a representative from a
national care home organisation and a social scientist with expertise in realist methodology. Three
meetings were held with the project steering group and 6 with the project team. Presentations were
structured to facilitate discussion of the plausibility of the programme theory, the supporting evidence
and possible variations and/or alternative explanations.
Patient and Public Involvement
One lay representative (family carer) was involved in designing the study and discussed resonance of
findings with their lived experience. Early findings were presented to two dementia research patient
and public involvement groups, two local GP patient participation groups and at engagement
meetings held in three care homes which included residents and family members.
Ethical approval
This realist review was a component of the Proactive Healthcare in Care Homes (PEACH) project. The
protocol for the whole project, including the realist review, was submitted to UK Health Research
Authority and University of Nottingham Research Ethics Committee; these committees identified the
project as service development. The study protocols have been reviewed as part of good governance
by the Nottinghamshire Healthcare Foundation Trust. Stakeholder practitioners who were invited to
be interviewed were given participant information sheets and asked for their informed consent prior
to interview.
Results
Following removal of duplicate articles, 694 articles describing Comprehensive Geriatric Assessment
(CGA) in older people’s care homes were screened by title and abstract by three reviewers (NC, MZ,
LS), and 110 were included in the review (Figure 1). A further 20 articles were retrieved by iterative
snowball literature search during stage 2. Nine interviews were held with stakeholders comprising a
care home manager, an occupational therapist, a GP, four community geriatricians, an old age
psychiatrist, and a social worker.
Following the initial analysis of the four articles which provided detailed description of CGA in care
homes, and the transcripts of scoping interviews during stage 1, a series of programme theories,
comprising “if… then…” statements, was written (Box 1).
If processes and structures (for example information technology systems, agreed assessment
protocols and opportunities to meet) are in place to facilitate a multi-domain assessment of all
needs of the individual resident, then this will lead to new insights and identification of care
priorities and gaps in knowledge about an individual’s status and needs.
If there are opportunities for all parties to discuss the significance of the comprehensive assessment
data and how the resident’s needs are addressed then, they will have a common understanding of
the resident’s situation and address and prioritise person-centred goals.
If practitioners are able to use the assessment data to agree shared goals for the individual, and the
care plan describes care activities and treatments which may lead towards such goals, then the
resident’s treatment is personalised leading to a good experience of care, staff satisfaction, and
reduced need for acute or crisis services.
Box 1 “If” and “then” statements following stakeholder interviews and preliminary scoping of the literature
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Whilst the “if… then…” statements were broad, they aligned how CGA works with literature on
interprofessional working (30), a recognition in the care home research of the intrinsic power
imbalances between health and social care staff during encounters (31), and the importance of
delivering minimally disruptive medicine to a patient group who do not fit acute and primary care
models of care (32). They also reflected three of the components previously described as constituting
CGA, namely structured comprehensive assessment, developing a plan of care, and working towards
the delivery of patient-centred goals (13).
Iterative review of the wider literature enabled us to further refine our initial programme theories to
delineate context, mechanism and outcome configurations. We were able to address the first two
objectives – identifying the elements which made CGA effective and considering how context
influences the implementation, uptake and working of CGA in care homes – but there were no studies
that explicitly addressed the feasibility of CGA in the UK care home setting and we were therefore
unable to address our third study objective regarding this. There were no studies which focussed
primarily on health-related quality of life but evidence that delivery of CGA was associated with
improved outcomes related to resident satisfaction(33), healthcare resource use(34), reduction of
polypharmacy(35) and objective measures of quality of care(27). See supplementary appendix 2 for
summary of all articles which informed the development and testing of theory.
The programme theories for the three components of CGA are described below and summarised in
boxes 2-4. Due to the information flow between these three components, they build on each other
in a way which is summarised in Figure 2.
Structured comprehensive assessment (Context Mechanism Outcome (CMO) 1)
The practices and processes of assessment inform the whole CGA (Box 2). Assessment of many
domains of health status and impairments was represented as crucial in building a picture of an
individual’s complex needs and views about their personal priorities and goals (36). Unlike discipline-
specific needs assessment that may focus on a particular syndrome or care pathway, structured
comprehensive assessment requires an overview of all domains (37).
The context of this component is the agreement and support of health and social care practitioners,
including care home staff, to work in a coordinated and collaborative team. Furthermore, the context
includes resources to enable the team to collaborate, including staff time and agreements on
information exchange. Unlike hospital-based studies (7-9) that can assume the presence of a
geriatrician and a predictable (therapist, nurse, social worker) multidisciplinary team (MDT), there was
evidence of greater variability in the professional groupings comprising the core MDT for CGA in the
care home setting. Team members are likely to represent different provider organisations, and so
strategic collaboration between organisations is another important context. Within the studies
included in this review, there was variability in the extent to which individual professionals making up
the MDT were available. In some studies, specific personnel were hired to deliver CGA (38).
Descriptions of team composition (27, 34, 39, 40) most frequently described a team comprising social
carers, nurses and a physician, with physiotherapists, occupational therapists or pharmacists added
to this in some situations. Bellantonio et al described a large team consisting of a geriatrician,
advanced nurse practitioner, physical therapist, dietitian, and social worker (34). The included articles
do not specify that geriatric training or qualification is a requirement for CGA, however geriatric
expertise or mentioned in two articles (26, 39){Panza, 2017 #1553}{Marshall, 2015 #1706}.
The mechanism-resources of the structured assessment are the protocols and various tools that are
administered while assessing each domain of CGA, such as the mini-nutrition assessment and Barthel
Index of activities of daily living (function) (33, 39). The Minimum Data Set (associated with the
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InterRAI system) has created a standardised battery of tools and developed a computer-aided
assessment protocol (41). We included articles describing MDS/InterRAI because it is described as a
comprehensive assessment which supports an interdisciplinary team (42). Here we interpret that, in
functioning to manage the care of an individual, InterRAI could be described as a technological
development of CGA that structures rather than triggers the assessment process. The computer-
facilitated multi-domain assessment is a mechanism-resource which enables an individual
practitioner, often a nurse, to conduct the initial assessments of the resident (36). The computer-
based algorithm may prompt further assessment by other members of the multidisciplinary team (27).
The literature to date does not include sufficient evidence to suggest distinct mechanisms, and
therefore we argue that the computer-facilitated assessment and the conventional CGA assessment
can be described by the same programme theory (box 2).
Facilitated by either conventional notes and assessment tools, or through computer-aided collection
of Minimum Data Set information, the mechanism-reasoning of the multidisciplinary team is to
reframe multiple accounts into a systematic representation of an individual’s health status (38). This
is in contrast to a conventional needs assessment which may focus on one domain or syndrome,
assessed by one professional.
“Taking stock of all observations, information and knowledge about a resident, and
understanding the resident’s limitations and strengths.” (Stewart et al 2003 (36))
The emphasis in the literature was on policy and practice development as an agent of change for care,
with the result that staff became more person-centred and better understood the different care needs
of the care home population. The processes of care driven by these contexts were not, however, well
described. Studies described staff listening to goals and expectations of residents in order to attend
to the identity of the whole person rather than a list of diagnostic categories (24). One paper also
described collecting family members’ views, using these largely as a source of information during
multidisciplinary meetings (34). With the standardised assessment, one study described how the third
iteration of the US minimum dataset (MDS3) instrument had been influenced by person-centred policy
context by including, within the questionnaire, opportunities to ask the resident open questions and
explore “subjective states” such as pain, mood and cognitive functioning (43). Bringing a focus on the
views of the individual resident may have changed attitudes within the multidisciplinary team to
create a mechanism of common understanding of the importance of knowing the resident, however
there was little evidence within the selected literature to support this mechanism.
The outcome of this component of CGA is primarily an improvement in quality of information about
the individual resident which is shared and reviewed over time amongst the multi-disciplinary team.
Contexts: A structured or standardised process, supported by a multi-disciplinary care team, with
resources available to conduct assessments with the resident.
Mechanism-resources: Protocols, tools and communication systems are ready-at-hand to enable
information about an individual’s health status and personal wishes to be recorded and shared
with the multi-disciplinary team. Information given by the spouse or family member of the
resident, or by care-workers may also be drawn upon, particularly when an individual has limited
capacity.
Mechanism-reasoning: Reframing multiple accounts into a comprehensive representation of an
individual’s health status rather than a description of syndromes.
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Outcomes: Overview of needs and goals of resident. Availability of information for transfer to
another setting.
Box 2 Context-Mechanism-Outcome Configuration for Structured Comprehensive Assessment
Developing a care plan (CMO 2)
The second component of CGA (Box 3) is about communication between practitioners that creates a
shared view of the priorities for delivery of care. The literature suggests that this part of the process
is more focussed around interprofessional communication, as involvement of residents or their
families is not explicitly described (44). The information generated by structured comprehensive
assessment about the needs and goals is the input for the multidisciplinary discussion and thus the
outcome of CMO 1 becomes a resource-mechanism for CMO 2.
The context for the second component is a structure for communication between the team members
in order to interpret a resident’s needs assessments (39). Practitioners may be based at a distant
location from the care home and therefore, to enable practitioners to work together, time needs to
be set aside for case conference meetings. The resources required for coordination and administration
of an MDT (and associated costs) are not described in the articles.
A Dutch trial reported that prior to the CGA intervention, attendance of GPs at the multidisciplinary
team (MDT) meeting was infrequent (25%) and, during the trial, this increased to 90% (27). Availability
of practitioners to discuss the assessment findings is the mechanism-resource which facilitates
communication between members of the team, for example in a case-conference meeting (40). This
meeting may occur regularly, for example monthly (27). Most studies did not explicitly state whether
the resident or family were invited to or attended team meetings and, where they did attend there
was no mention of them doing much more than providing information. The members of the meeting
included nurses, primary care doctors and care home managers. In some studies, geriatricians or
therapists were also specified as part of the team (27, 34).
Different professional or disciplinary perspectives on the needs and care requirements of the
individual may be discussed in multi-disciplinary team communications. The team discussion prompts
the mechanism-reasoning which is to create a unified view of priorities for the care plan for the
individual (26). Topic specialists may contribute to assessment and pool their expertise with the team,
facilitating working towards common goals for the individual resident, or continuity of care (39).
“…trained professionals who design a shared disease management plan” (27)
The outcome of practitioner teamwork is to develop a comprehensive care plan. An immediate
outcome may be referrals to other practitioners, external to the team. One study, for example,
showed an increase in referrals to allied health practitioners, hospital at home service and palliative
care (33). The same study found small decreases in hospital readmission rates, suggesting that these
community referrals may mitigate against hospital attendance. Changes in prescribing were also
reported as an important immediate output from the second component of CGA (40).
Context: Communication between multidisciplinary practitioner team members from different
organisations.
Mechanism-resources: Case-conference discussion of the comprehensive structured assessment
to gain an understanding of aims and priorities of individual.
Mechanism-reasoning: Developing a unified view and shared aims and goals for the resident
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Outcome: A comprehensive care plan is developed and prescriptions updated.
Box 3 - Context-mechanism-outcome configuration for Developing a Care Plan
Working towards the delivery of patient-centred goals (CMO 3)
The outcome of the comprehensive care plan, becomes the resource-mechanism for the next stage of
CGA, which focusses on working towards the delivery of patient-centred goals (45). It was often
explicit within articles that a care plan was implemented as part of CGA but there was less emphasis
on standardisation at this stage than during structured comprehensive assessment. There was at
times a recognition of the need to file the outputs of the assessment process but it was not made
explicit whether these were in the form of structured assessment outputs or specific care plans. An
example is the ‘Care by Design’ programme, reported by three Canadian articles within our review,
which specified inclusion of a summary document of assessment information in the resident’s medical
chart (26, 35, 38). The authors describe the expectation that this summary sheet would be considered
by all care staff and transferred with the resident to urgent care hospital. However the form appears
to be the same form which has been used to collect the summary comprehensive assessment
information, rather than a care plan generated out of multidisciplinary discussion.
Three articles described care planning within the InterRAI algorithm-driven system. This has a series
of predesigned Resident Assessment Protocols that lead to Comprehensive Care Plans. The latter
appear to address syndromes or diseases, rather than being truly comprehensive (46). Two articles
described problems perceived by care assistants when implementing care plans, suggesting either a
lack of resources or an emphasis on a systematic approach over individualisation; care assistants
reported feeling disempowered and uninvolved in decision making (47, 48).
Whilst the specific format of the care plan is not described in detail, the outcome is delivery of care
activities in a coordinated way. Empirical outcomes include improvements in quality of care, and
reduced transfers to hospital for urgent care (27, 33, 34).
Context: Coordination of care activities.
Mechanism-resources: Resident may be referred to topic-specialist practitioners to give further
assessment and together with team members refine the care plan.
Mechanism-reasoning: Delegation from the multidisciplinary team to care home staff provides
authority to deliver care according to the care plan.
Outcome: Resident perceives continuity of care and early intervention either prevents
deterioration of needs or provides a palliative response. Unnecessary care is avoided.
Box 4 Context-mechanism-outcome configuration for Working Towards the Delivery of Patient-centred Goals
A Programme Theory of CGA in Care Homes
Figure 2 outlines the nested configurations of CMOs for CGA in care homes, where outcomes of earlier
stages form the mechanism-resource for later stages. This makes it clear how each CMO builds on the
one before.
The delivery of CGA in care homes was dependent on two contexts, how feasible it was for
professionals to participate and whether the use of a structured assessment created the sense of a
common purpose challenging discipline-specific approaches and behaviours. We heard initial
suggestions from our stakeholders that the CGA process could mitigate differences in disciplinary
status to enable more balanced power relationship between all clinicians, social workers and care
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home staff. However, we found minimal explicit statements within the selected evidence to suggest
that this had been considered.
Several articles support the outcomes of CGA in terms of health benefit and delivery of healthcare
services. Responses from resident and family perspectives indicated a positive experience or
satisfaction with services (25, 33). Practitioner team members also reported positive outcomes of
CGA, although for programmes that involved computerised information, care home staff identified a
challenge with access to computers to enter data and read care plans, meaning that staff felt excluded
from sharing views on care plans (47).
Discussion
We were able to find evidence of how comprehensive geriatric assessment operates in care homes
and we have developed a programme theory demonstrating how the processes identified map to the
way in which Comprehensive Geriatric Assessment (CGA) is described to take place in hospital and
community settings. Effective delivery of CGA requires a structured or standardised approach to
assessment, followed by communication within a multidisciplinary team and co-ordination of care
delivery activities. The evidence suggests that for CGA to be effective all three of these components
must be present.
The strength of this realist review is in the structured approach, with putative “if… then…” statements
shaped by insights from stakeholder interviews, followed by systematic literature search and iterative
development of programme theory guided by frequent and repeated recourse to the published
literature. The resulting programme theory is based upon insights from multiple studies where
consistent patterns of association between context, mechanisms and outcomes have been found. By
using scoping interviews and an expert project steering group we were able to make the greatest
possible sense of the limited literature in a structured and robust way.
A significant limitation of the work is that, by limiting the studies to those which explicitly used CGA
as a descriptor, we may have missed out research using other conceptual frameworks to describe
multi-disciplinary and integrated care in care homes. It is possible that these frameworks may have
overlapped sufficiently with CGA and would have shone further light on our theoretical framework
had we extended our search to include them. We defend the decision not to include them because
interventions which may have similar aims, but which do not comply with our stated characteristics
of CGA are unlikely to have identical mechanisms, if considered from a realist evaluation perspective.
The weight of evidence was greatest for processes of assessment, whilst less data were available on
processes of developing a care plan and working towards patient-centred care.
To our knowledge this is the first realist review of CGA in care homes. A recent systematic review
summarised characteristics of different assessment tools used to support the CGA process, but did
not synthesise the processes and relationships (39). This current review builds on that research by
providing greater detail of how CGA works in care homes, and under what circumstances.
The programme theory provides a framework which will be of use to providers developing,
implementing and evaluating the efficacy of CGA. It also has some explanatory value when
considering why interventions aiming to co-ordinate care in care homes using assessment protocols
or pathways have not always been shown to be effective (49, 50). Our realist review suggests that the
engagement of a multidisciplinary team with regular communication to enable development of a care
plan, followed by co-ordinated delivery of this, is at least as important as the assessment frameworks
used.
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An important finding was the tension between standardised forms of assessment (MDS or InterRAI),
compared to the development of tailored or person-centred care plans in both InterRAI and
conventional CGA (51). The theory of competing institutional logics, of standardisation and
customisation (52), may help to interpret this tension. For the standardised assessment (MDS) the aim
is to generate standardised data in order to be comparable for analysis, however customisation is
required to enable the multidisciplinary team to develop a care plan to meet the complex needs of
the individual. Good communication within the multidisciplinary team is important to address this
tension between standardisation and customisation. Indeed a previous realist review of integrated
care programmes in the community identified trust as the important mechanism leading to outcomes
of improved patient experience and health (53). The idea that CGA provides an opportunity where
professionals from different teams and organisations can come together with residents to establish
shared priorities for healthcare of a resident is similar to the concept of “communicative space”
described elsewhere in the literature (54). This has been suggested to be particularly important in care
homes because they are contested places where neither professionals nor residents may feel fully in
charge of events.
Despite limiting our search to literature on care homes, there was a lack of explicit description about
how CGA was tailored specifically to the care home setting. For example, there were limited
descriptions of how staff and other resources should be organised to optimise CGA within care homes.
There was little description of the training or competencies required to enable CGA in a sector of
health and social care where it is not routinely delivered. This made it difficult to address our third
study objective around the feasibility of CGA in UK care homes. Further work is required to better
understand the care home-specific aspects of CGA which are essential to guide new practitioners as
they attempt to implement CGA in the sector.
Conclusion
In summary, this work provides a programme theory which describes how Comprehensive Geriatric
Assessment works in care homes. CGA has three components: a structured or standardised approach
to assessment, followed by communication within a multidisciplinary team and co-ordination of care
delivery activities. Unless all three of these components are addressed, CGA is unlikely to be successful
in this setting. This new understanding provides the basis for more evidence-based approaches to
service development and audit in the field. The programme theory provides the basis for further
research around the implementation of CGA in this sector.
Contributorship
Neil Chadborn, Maria Zubair and Lídia Sousa carried out searches, data extraction and theory was
developed together with Claire Goodman and Adam Gordon. Neil Chadborn, Claire Goodman and
Adam Gordon conducted synthesis with reflections and amendments from John Gladman, Tom
Dening, and other authors. All authors have read and approved the final version.
Competing Interests
The authors declare no competing interests
Funding
This work has been undertaken as part of the Proactive Healthcare in Care Homes (PEACH)
study, funded by the Dunhill Medical Trust, award no FOP1/0115.
Data sharing statement
This is a review of published literature
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Acknowledgement
The PEACH study research team are, in addition to the authors: Mr Zimran Alam, Ms Anita Astle,
Prof Tony Avery, Dr Jaydip Banerjee, Prof Clive Bowman, Mr Michael Crossley, Dr Reena Devi, Prof
Heather Gage, Dr Kathryn Hinsliff-Smith, Ms Gemma Housely, Dr Jake Jordan, Dr Sarah Lewis, Prof
Pip Logan, Ms Annabelle Long, Prof Finbarr Martin, Prof Julienne Meyer, Dr Dominick Shaw, Prof
David Stott and Ms Adeela Usman.
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Figure 1 Schematic of flow of articles within review
Figure 2 Nested arrangement of CMO configurations
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RAMESES checklist Location in text and additional comments
1TITLE Includes key terms 'care homes' 'Comprehensive Geriatric Assessment' and 'realist review'
2ABSTRACT
Programme theory is summarised. Also Strengths and Limitations of the method of the review are
given
INTRODUCTION
3 Rationale for review
To describe the components of CGA, how they are applied within the care home setting and what
outcomes have been reported
4 Objectives & focus Introduction; Objectives of Realist Review
METHODS
5
Changes in the
review process
Change in search terms; not using Geriatric Assessment MeSH term.
Presentations were given in care homes, but residents were not interviewed due to difficulty
conveying putative theory of CGA
6
Rationale for realist
synthesis
Introduction; Objectives of Realist Review
7 Scoping the literature
Methods; Stage 1. Stakeholder interviews, consultation with programme group of PEACH, PPI.
Advised that scope should be CGA in care homes, therefore excluded Evercare community matron
literature. Included InterRAI where this is used for care planning
8 Searching processes
Methods; Stage 1. Requested literature from programme group of PEACH, discussed on twitter
meaning of CGA, spoke to senior professionals in OT & SLT. Searches focused on CGA in CH, with
wider reading of MDT and care planning literature.
9
Selection and
appraisal of
documents
Methods; Stage 2. Relevance to rough programme theory. Preference for empirical data for
outcomes. Articles whose scope was epidemiological study or study of one specific clinical topic
were excluded
10 Data extraction
Methods; Stage2. Text of articles was coded according to relevance to 3 'nested' CMO
configurations. Emphasis on configuration (not simply listing M's and O's) and relationship
between CMOs
11 Synthesis processes
Methods; Stage 3. Focus on multidisciplinary perspectives, technologies that facilitate this,
processes to ensure personalisation or person-centred
RESULTS
12
Document flow
diagram
Flow schematic - Fig 1.
13
Document
characteristics
Table of articles - Appendix 1. Includes description of type of study, quality and usefulness for this
review, summary of outcomes relevant to this review
14 Main findings Theory building - 3 CMO configurations. Difficulty in testing phase due to limited literature
DISCUSSION
15 Summary of findings
Description of programme theory in CMO configuration, giving contrast to published systematic
reviews
Overall strength of evidence for description of theory of how CGA works in practice. Strength of
comprehensive search of literature and extraction of data on context.
Limitations; lack of evidence on the specific process of converting the assessment into the care
plan
Gaps identified for future research; lack of evidence of how communication between
professionals occurs in practice, lack of evidence of how care plans are put into practice by care
assistants, lack of evidence of how residents and family are involved in decision-making
17
Comparison with
literature
Existing literature focuses on assessment tools but little about processes and teamwork; these
are implicit rather than described
18
Conclusion and
recommendations
We present a programme theory for CGA in care homes and recommend that this can be used to
support quality improvement and future research
19 Funding Dunhill Medical Trust
16
Strengths, limitations
and future research
directions
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First author Year Ref # Type of study Setting Location Population Assessment or Intervention
Quality of data
extracted*
Adra 2017 23 Grounded theory Nursing home Lebanon - Unstructured 2
Andrew 2018 34
Observational
before/after
Care home Canada - LTC-CGA / Care by Design 2
Marshall 2015
11, 25,
37
Mixed methods Care home Canada Average age 85 LTC-CGA / Care by Design 3
Bellantonio 2008 33 RCT Assisted living US Dementia
Systematic multidisciplinary
assessment
3
Harvey 2014 32 RCT Residential home Australia 65yrs & older RECIPE / Postdischarge 3
Banerjee 2015 47 Qualitative review Care home Canada - MDS/RAI 1
Boorsma 2011 26 Cluster RCT Residential home Netherlands 75yrs & older RAI-LTCF(web)
3
Challis 1999 40 Review Care home UK - MDS/RAI 1
Dellefield 2015 45 Review Care home -
Comprehensive care plan
MDS/RAI
1
Holtkamp 2001 24
Non-randomised
controlled study
Nursing home Netherlands
Mean age 76 &
83
MDS/RAI
3
Kontos 2009 46 Qualitative Nursing home Canada - MDS/RAI 2
Thomas 2014 42
Retrospective cohort
analysis
Nursing home US Average age 80 MDS3
3
Salva 2009 44 Review & consensus Care home - -
MDS / Mini-Nutritional
Assessment
1
Stewart 2003 35 Editorial Care home - - MDS/RAI 1
Burns 2011 39 Narrative review Care home - - Medication review 1
Bien 2005 43 Narrative review
Hospital, care home,
community
- - - 1
Worden 2006 36 Observational Care home UK - - 2
Panza 2017 38 Systematic review Care home - - - 3
Meyer 2009 50 Editorial - - - - 1
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First author Year
Adra 2017
Andrew 2018
Marshall 2015
Bellantonio 2008
Harvey 2014
Banerjee 2015
Boorsma 2011
Challis 1999
Dellefield 2015
Holtkamp 2001
Kontos 2009
Thomas 2014
Salva 2009
Stewart 2003
Burns 2011
Bien 2005
Worden 2006
Panza 2017
Meyer 2009
Outcome 1 Outcome 2 Outcome 3
Polypharmacy (>10 meds) decreased from 86.8% to 79.5%
Advanced directive 56.4%
Information transfer for emergency care
significantly increased (P < .001)
Decreased unanticipated transitions (13%),
hospitalisations (45%), emergency transfers
(12%), death (63%)
Advanced directive increased from 13% to 67%
Decreased outpatient visits from 76%
to 37%
Satisfaction increased from 58% to 95%
40 MDTs were held
Quality of care mean difference -6.7 (p = 0.009)
medium effect size 0.72
Number of identified needs increased in experimental;
decreased in control
Identified oral & dental needs
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