Integrated Care with GP Participation for Older Persons in the Ambulatory Care Hub: a Prospective Cohort Study.

NCT05527223 | Completed

• 1 other identifier: 116/2021
• Study Type: observational
• Target: 303
• Locations: 1 country
• Sites: 1

Brief Summary

Comprehensive Geriatric Assessment (CGA) demonstrates positive outcomes amoung community-dwelling older people living with frailty. However, there is currently no evidence of benefit for CGA with General Practitioner (GP) participation within the Irish Primary Care setting. This study aims to explore the clinical and process outcomes of older adults living with frailty who are screened by and referred to one of the three Ambulatory Care Hub's in the primary care setting in the Mid-West of Ireland by their GP, where they undergo a CGA .

Conditions

Frailty; Comprehensive Geriatric Assessment

Outcome Measures

Primary Outcomes (2)

• Incidence of functional decline

  The number of participants who experience functional decline or do not as measured by the Barthel Index (BI). Functional decline is defined as a net decrease in the number of activities of daily living performed independently as measured by the self-reported BI. The sum of all of the 10 subscales of the BI ranges from 0-20 points where a higher score indicates increased independence.

  30-days

• Incidence of functional decline

  The number of participants who experience functional decline or do not as measured by the Barthel Index (BI). Functional decline is defined as a net decrease in the number of activities of daily living performed independently as measured by the self-reported BI. The sum of all of the 10 subscales of the BI ranges from 0-20 points where a higher score indicates increased independence.

  6-months

Secondary Outcomes (11)

• Primary healthcare use (within and outside of ACH healthcare utilisation)

  30-days

• Primary healthcare use (within and outside of ACH healthcare utilisation)

  6-months

• Secondary healthcare use

  30-days

• Secondary healthcare use

  6-months

• Quality of integrated care from the perspective of participants

  30-days

Eligibility Criteria

• Age: 75 Years+
• Sex: all
• Healthy Volunteers: No
• Age Groups: Older Adult (65+)
• Sampling Method: Non-Probability Sample

Study Population

All older adults aged ≥75 years who are referred to the ACH by their GP between February 2022 and January 2023 (inclusive) will be considered eligible for participation in the study, if they meet the inclusion criteria.

You may qualify if:

• Referred to the ACH by their GP
• Score between 4 and 6 on the Rockwood Clinical Frailty Scale
• Reside within CHO 3 and the catchment area of the relevant ACH hub
• Have been assessed in-person by the referrer
• Has not had MDT input within the last three months
• And any one of the following criteria:
• 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 or experienced an adverse drug reaction within the last month excluding allergic reaction.

You may not qualify if:

• Patients will be excluded if they:
• 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

Sponsors & Collaborators

• University of Limerick: lead

Study Sites (1)

School of Allied Health, University of Limerick.

Limerick, Munster, V94 T9PX, Ireland

Location

Related Publications (9)

• Liljas AEM, Brattstrom F, Burstrom B, Schon P, Agerholm J. Impact of Integrated Care on Patient-Related Outcomes Among Older People - A Systematic Review. Int J Integr Care. 2019 Jul 24;19(3):6. doi: 10.5334/ijic.4632.

  PMID: 31367205 BACKGROUND

• Mann J, Thompson F, McDermott R, Esterman A, Strivens E. Impact of an integrated community-based model of care for older people with complex conditions on hospital emergency presentations and admissions: a step-wedged cluster randomized trial. BMC Health Serv Res. 2021 Jul 16;21(1):701. doi: 10.1186/s12913-021-06668-x.

  PMID: 34271945 BACKGROUND

• World Health Organisation. Integrated Care for older people: Realigning primary health care to respond to population ageing. 2018.

  BACKGROUND

• Everink IHJ, van Haastregt JCM, Tan FES, Schols JMGA, Kempen GIJM. The effectiveness of an integrated care pathway in geriatric rehabilitation among older patients with complex health problems and their informal caregivers: a prospective cohort study. BMC Geriatr. 2018 Nov 16;18(1):285. doi: 10.1186/s12877-018-0971-4.

  PMID: 30445923 BACKGROUND

• Roe L, Normand C, Wren MA, Browne J, O'Halloran AM. The impact of frailty on healthcare utilisation in Ireland: evidence from the Irish longitudinal study on ageing. BMC Geriatr. 2017 Sep 5;17(1):203. doi: 10.1186/s12877-017-0579-0.

  PMID: 28874140 BACKGROUND

• Briggs R, McDonough A, Ellis G, Bennett K, O'Neill D, Robinson D. Comprehensive Geriatric Assessment for community-dwelling, high-risk, frail, older people. Cochrane Database Syst Rev. 2022 May 6;5(5):CD012705. doi: 10.1002/14651858.CD012705.pub2.

  PMID: 35521829 BACKGROUND

• Glynn LG, Valderas JM, Healy P, Burke E, Newell J, Gillespie P, Murphy AW. The prevalence of multimorbidity in primary care and its effect on health care utilization and cost. Fam Pract. 2011 Oct;28(5):516-23. doi: 10.1093/fampra/cmr013. Epub 2011 Mar 24.

  PMID: 21436204 BACKGROUND

• World Health Organization. World report on ageing and health: World Health Organization; 2015

  BACKGROUND

• Hayes C, Whiston A, Fitzgerald C, Devlin C, Condon B, Manning M, Leahy A, Robinson K, Galvin R. Community Specialist Teams for Older Persons (CST-OP) at risk of, or living with frailty in Ireland: a prospective cohort study of a new model of integrated care for community dwelling older adults. BMC Prim Care. 2025 Jun 5;26(1):193. doi: 10.1186/s12875-025-02895-x.

  PMID: 40474059 DERIVED

MeSH Terms

Conditions

Frailty

Condition Hierarchy (Ancestors)

Pathologic Processes; Pathological Conditions, Signs and Symptoms

Study Officials

• Rose Galvin

  University of Limerick

  STUDY DIRECTOR

Study Design

• Study Type: observational
• Observational Model: COHORT
• Time Perspective: PROSPECTIVE
• Sponsor Type: OTHER
• Responsible Party: SPONSOR

Study Record Dates

• First Submitted: August 11, 2022
• First Posted: September 2, 2022
• Study Start: February 2, 2022
• Primary Completion: December 30, 2023
• Study Completion: December 30, 2023
• Last Updated: February 10, 2025

Record last verified: 2025-01

Locations

IE (1)