Comprehensive geriatric assessment of frail older people: ideals and reality

ABSTRACT

We explored different professionals’ views on and experiences of comprehensive geriatric assessment (CGA) of frail older people. Forty-six professionals working in hospitals, primary care, or municipal health and social care participated in 10 focus groups. Professional groups comprised of occupational therapists, physiotherapists, nurses, physicians, and social workers. Participants shared an ideal image of how the CGA of frail elderly people should be conducted. Experience-based competence was more often used as an assessment tool than standardized tests. The ideal image contrasted with reality, listening to the needs expressed, with the person’s problems, needs, and priorities in the foreground, as described by the categories: a need that can be met; different perspectives on needs; needs can be hidden; and needs assessment is affected by the collaboration around the person, by the context, and by the dialogue. The health and social care professionals’ first priority is to make a person-centred tailor-made comprehensive geriatric assessment and not be bound to instruments. Clear guidelines need to be developed, stating which profession assesses what, when and how in order to ensure that person-centred needs are assessed including structures and procedures for how communication and collaboration within the team as well as between the organizations are achieved in order to perform a good person-centred CGA.

KEYWORDS:

• Focus group method
• interprofessional team
• person-centredness
• professionals’ views

Introduction

Frailty is considered to be highly prevalent in old age among people 65 years and older, increases by age and entails a high risk of falls, disability (Collard, Boter, Schoevers, & Oude Voshaar, 2012), multimorbidity, hospitalization, and mortality (Fried et al., 2001; Morley et al., 2013). The frail older population often requires health and social care from different providers with expertise in various fields, such as geriatrics, nursing care sciences, rehabilitation, and social work. Consequently, older adults may have to consult with a range of professionals from different disciplines. Health and social care services are not always fully integrated and often focus on one problem at a time, resulting in a risk of fragmented care across the continuum of care (Ahgren, 2010).

Fragmentation across different levels of health and social care may hinder the process of care and rehabilitation for frail older people. Poor coordination across departments, insufficient collaboration and little shared work experience among health professionals may hinder the process of care and rehabilitation (Reeves et al., 2011). This complicates identification of risk factors that may lead to deterioration in health status, and can result in less reliable assessments of frail older people. One way to secure frail older people’s needs effectively (Caplan, Williams, Daly, & Abraham, 2004) is to use comprehensive geriatric assessments across the continuum of care. This method has been introduced in many countries (Rubenstein, 2015). A well-performed CGA ought to be both multidimensional and interprofessional (SBU, 2014). To be multidimensional means assessing an older person’s domains such as medical, functional, psychosocial, and environmental needs (Rubenstein, 2015; Rubenstein, Siu, & Wieland, 1989) and requires an interprofessional team approach that includes (at least) medical expertise, nursing, social care, occupational therapist, and physiotherapist.

Interprofessional teamwork has been defined as “an intervention what involves different health and/or social professions who share a team identity and work closely together in an integrated and interdependence manner to solve problems and deliver services” (Reeves and Lewin 2010) strengthened by other researcher as well (Baker, Egan-Lee, Martimianakis, & Reeves, 2011; Duner, 2013; Thylefors, Persson, & Hellstrom, 2005). This is a prerequisite for achieving team benefits (Headrick, Wilcock, & Batalden, 1998) and a high degree of patient and staff satisfaction (Åberg & Ehrenberg 2017). Interprofessional collaboration is known to be necessary to enable quality, safe, and accessible health care (Hurlock-Chorostecki & McCallum, 2016). Limited understanding of each other’s roles and responsibility can affect the interprofessional team approach (Baker et al., 2011). The goal is to identify needs and provide support to help the older person maintain independence in their daily living and quality of life; in other words, ageing well at home. Different professionals construct collaboration in very different ways and can have competing concepts of what constitutes collaborative work (Reeves & Lewin, 2004). However, communication is often fragmented resulting working separately rather than in a cohesive interprofessional care (Reeves & Lewin, 2004).

As stated by the American Geriatrics Society Expert Panel on Person-centred Care (2016), person-centred care is an approach to improve healthcare safety, quality, coordination, and quality of life among older frail people. Their definition of person-centred care means that individuals’ values and preferences, guide all aspects of their healthcare, supporting their realistic health and life goals. Person-centred care is achieved through a dynamic relationship on equal terms among the older person, others who are important to them, and all relevant providers. This collaboration informs decision-making to the extent that the individual desires (D’Amour, Goulet, Labadie, Martin-Rodriguez, & Pineault, 2008; Hurlock-Chorostecki & McCallum, 2016). By identifying the main obstacles to implementing person-centred CGA, the healthcare system can move towards solutions and improve the quality of care for older adults, especially those with complex care needs (Jags, 2016).

Fragmented care complicates the communication required to perform an effective, comprehensive geriatric assessment across the levels of care. To ensure the assessment is as comprehensive as possible, without unnecessary duplication, and to use existing resources wisely, there is a need for knowledge about the content of, and different professions’ contribution to CGA. Therefore, this study aimed to explore different professionals’ views on and experiences of comprehensive geriatric assessment of frail older people throughout the continuum of care. To our knowledge, research on comprehensive geriatric assessment of this kind has not yet been performed.

Methods

A focus group method was used to explore different professionals’ views on and experiences of comprehensive geriatric assessment.

Setting

The study took place in clinical settings throughout the continuum of care in the western part of Sweden. In Sweden, the organization of elderly care is based on peoples’ right to live at home for as long as possible regardless of illness or disability. When frail older people, are discharged from hospital, various professionals from both the hospital (nurses, physiotherapists, occupational therapists, hospital social workers), the municipality (care managers, nurses, physiotherapists and occupational therapists) and the primary care (physicians, nurses physiotherapists and occupational therapists) are obliged to collaborate to ensure that the patient’s overall needs will be met at home. At discharge, the municipality care manager is responsible for assessing and deciding on home care services and/or short-term or permanent residential home placements. In order to make an appropriate care plan, the care manager needs to collect information about the patient’s current resources and needs from other professions, such as nurses, occupational therapists, physiotherapists, hospital social workers, and physicians from the hospital. Moreover, the care activities (e.g. rehabilitation, medical care, social care) need to be coordinated and distributed among professionals with the right competence (The Government of Sweden, 2018).

Participants

The participants were recruited by purposeful sampling by identifying the professionals who most frequently work with older people throughout the continuum of care. This includes different levels of care in clinical settings, such as university hospital, primary care centers, and municipal health and social care centers. The managers of each health organization concerned were contacted with information about the study and their approval was sought. The managers provided names of professionals with knowledge and experience of the topic of interest. These were contacted and provided with both written and verbal information about the study. Participation was voluntary, and all those who volunteered participated in focus groups with representatives from the same profession and the same care provider, with the exception of physicians, who came from different care providers. Ethical approval was obtained for the study ref. No: 650–07.

In total, 46 professionals participated in 10 focus groups: two occupational therapist groups (OT, n = 11), two physiotherapist groups (PT, n = 12), two nursing groups (RN, n = 6), two physician groups (MD, n = 9), and two social worker groups (1 group were care managers (CM, n = 5) from the municipality, responsible for needs-assessment and decision-making on social care services after discharge, and 1 group of hospital social workers (HSW, n = 2), providing psycho-social support at the hospital. Homogeneity and heterogeneity are important when selecting focus group participants (Krueger & Casey, 2015). The participants were homogeneous in their respective groups because all participants belonged to the same profession, the same care providers (hospital, primary care, and municipal health and social care), except the physicians and all were involved in the assessment of frail older people in order to facilitate the discussions. Participants in the focus groups were heterogeneous in terms of age, sex, and length of work experience in order to ensure variation in the target group.

Procedure

The focus group discussions were conducted in a conference room in the clinical setting or at the university. Each focus group met once for up to 2 h. The focus group discussions were led by two researchers who functioned as moderator and co-moderator. All moderators and co-moderators had experience in working with groups. The co-moderators were from the same profession as the focus group participants (OT, PT, RN, CM, HSW, or MD), whereas the moderators were from a different professional background to the focus group participants. This was because we did not want the group leader to be an expert on the topic, as this might have inhibited the discussions. The moderator’s task was to pose questions to deepen the discussion and ensure that participants who were silent were given a chance to speak promoting interaction among participants.

Data analysis

The qualitative data analysis used was based on the framework of analysis developed by Krueger (Krueger & Casey, 2015) as it helps to analyse the large and complex nature of focus groups discussions. To become familiar with and to understand the content of the material in its context, the first analysis step was to listen to the audio-recordings several times. The transcripts of each focus group discussion were then read carefully and independently by all authors to develop a sense of the discussion as a whole. Sections of the discussion relevant to the research topic were identified and sorted into different themes. Revisiting the purpose of the study guided the process of summarizing the data. At this stage, the working material was still in the form of raw data to promote understanding of the contextual meaning. Based on this raw data, we defined the categories that emerged from the material and constructed descriptive statements synthesizing, abstracting, and conceptualizing the data. The last step was to summarize the categorized raw data, combined with an interpretative step that aimed to provide understanding.

Results

Ideal versus reality

According to the participating professionals, frail older people do not have the same opportunity for assessment throughout the healthcare chain because of the lack of mutual guidelines and routines for needs assessment. In addition, the use of CGA and how it was implemented depended on where the frail older person was within the organization. A common starting point for all professions was based on a unique assessment of each person as an ideal image, but participants noted that this ideal image constantly contrasted with reality.

Ideal image

Participants considered there should be a unique evaluation for each frail person, with a well-performed assessment based on the older person’s own perspective of what was important. This entailed listening to the needs expressed, with the person’s problems, needs, and priorities in the foreground. Frail older people are a heterogeneous group, and each individual’s needs in assessment is not like another’s; a flexible approach is needed to provide a unique assessment for each person. Therefore, experience-based knowledge and competence were used as assessment tools more than standardized tests; questions tailored to the person to capture that person’s needs were used even though a multidimensional approach characterized the assessment. Having experience and competence gave a picture of the person being assessed that more clearly showed that person’s experienced needs. The ideal image contrasted with reality, as described by the emerged categories: a need that can be met, different perspectives on needs, needs can be hidden, and needs assessment is affected by collaboration around the person, by the context and by the dialogue.

Real image

Only needs that can be met

Currently, only needs that matched available interventions or services are assessed. Other needs cannot be resolved (i.e., not treated at that care level), the professionals do not have the skills, or they do not have the necessary resources. Professional groups also tended to stick to the problem areas that profession can “fix”; they were reluctant to encroach onto each other’s territory. This means that certain questions could not be asked because of the awareness that nothing could be done. Participants reported that the resources and organizational conditions set the agenda more than the person’s real needs.

Focus group with occupational therapists

P1.

If they have residential housing, no questions are put, nothing more is done than maybe try and train back to the original status, but I hesitate if they even do that

I:

Is that a problem do you think?

P.

I don’t think the ward sees it as a problem,

P2.

They probably think it’s a good, flexible solution

P3.

It’s flexible, yes, ha ha

P1.

Obviously there’s a lot that could be missed then. When you presume that all needs have been satisfied as they already have accommodation, and especially when we, in what we’re talking about, really do miss out on understanding this problems.

Different perspectives on needs

What constituted a need was unclear. There were different ways of looking at needs within professions, and different views on whether needs were over- or underestimated. Organizational and professional guidelines controlled professionals’ priorities in assessing needs. There were also different profession-specific perspectives (“lenses professionals wear”) when assessing needs, with needs appearing differently among occupational groups. These different perspectives may also have different strengths of appeal, which affected the assessment in various ways. The discussions highlighted that needs became clearer when there was opportunity to use each other’s expertise/competence, which was identified as an important prerequisite for effective needs assessment.

Focus group with nurses

P1:

We have slightly different ways of looking at this sort of thing. To take a final fishing trip out with the grandchildren before you die we think is self-evident, whilst they see it as being more important to have them home - we see things differently. We think, like, the wheelchair should be fixed so that all we have to do is to go and fetch it. But it hasn’t arrived.

P2:

I think there should be better collaboration between the roles so that you can get the help.

P3:

What’s more important, I can think the wheelchair might be more important than washing myself in certain situations, but we have different priorities. And those might be in order to manage the situation. They probably have their own very good reasons for things we don’t know about.

I:

So it’s an organisation order of priorities or is it a professional order?

P1:

No, it’s probably organisational as it’s not up to the individual therapists but is ruled on higher up in order for things to function maybe.

Needs can be hidden

The importance of being open to hidden needs (a facade can be deceptive) was emphasized in different ways. In particular, this applied to mental and cognitive functions. Older people want to preserve their privacy and may not want to show (or are not aware that they have) cognitive problems. “Tension” can arise between the needs the person displays and the actual problems that arise in various everyday situations. Participants reported it was difficult to assess these hidden needs, and assessors may miss some needs or lack the knowledge required to assess these functions. This affected the content of the needs assessment.

Focus group with occupational therapist

P1:

Well it could be, for example, that you start to suspect something cognitive but you can’t really be sure, however you might think that patient said something wrong there even though it will be right next time. It’s really difficult, this.

P2:

And then what is healthy and what’s starting to get sick. What’s allowed to be normal?

P3:

And has this person been this way all of their life? It’s difficult, too.

Needs assessment affected by the collaboration around the person

Participants highlighted the importance of using the knowledge acquired from the people around and close to the person being assessed, as well as sharing knowledge among different professional groups to achieve a nuanced view. The population of frail older people varies; they may be frail in different ways, and frailty can differ between weeks and days or during a single day. For the image of the person to be as “true” as possible, a picture that is as complete and as nuanced as possible about the needs of that person is required. Collaboration between professionals making the assessments and the people who work closely with the older person (e.g., nurses, home care professionals, and family) did not always work; this also applied to collaboration between professions. This may lead to repetition of questions, which receive responses from the person under assessment such as “Don´t you communicate with each other here?” and “You are the third person asking me if I have stairs at home.” Communication and structural barriers within and outside each organization hampered collaboration.

Needs assessment influenced by context

Participants noted that people’s needs vary in different environments depending on that person’s context. It was only when a person was in their own home that the reality of their needs became evident. Usually, assessments are performed in locations such as a hospital, a physiotherapy unit, or an occupational therapy department, and not the context or environment that the person must return to or live in. Therefore, the risk of under- or overestimating the person’s ability has implications for assessment, meaning assessment might not be as optimal as it could have been under other conditions.

Needs assessment affected by the dialogue

Participants highlighted the need to approach needs assessment from different angles and directions to capture a person’s needs and problems effectively. This required learning how to phrase questions properly and listen carefully (e.g., “reading between the lines”). It entailed learning to listen for the right things, which largely concerned experience but also patience, as many people need time. Participants noted that it was people are likely to have disabilities such as impaired hearing or cognitive dysfunction. Therefore, the questions asked must capture the person’s needs in the context of the time they have at their disposal. This was not always possible due to lack of time, which in turn might have affected the assessment not always possible to ask a question and expect a quick response, especially as older

Focus groups with physiotherapist

P1:

Yes, you have to put open questions many times.

P2:

Yes you have to. As you say, you put a question and then get an answer but if you put a follow-up question you may get a completely different answer.

P3:

Yes, that’s true like when you ask if they’re otherwise feeling healthy, they answer yes. If you ask if they take any medication they say, yes I have a load of medicines ha ha

P1:

Ha ha, quite right.

P3:

But they see themselves as healthy, I’m healthy when I take this medication, as I don’t get sick. It’s quite logical in fact. You put one, two three questions about the same thing really in order to get that far.

Discussion

The main finding of this study was that the participating professionals shared an ideal image of how the assessment of frail elderly people should be conducted. In essence, each assessment should be unique, with the older person’s own problems, needs, and priorities at the forefront. The ideal image experienced by the participants is that experience and competence were more used as assessment tools than standardized tests, as they more clearly showed the person’s own experienced needs. This shared image is consistent with the person-centred approach, with all decisions that affect a person’s care are based on partnership (Ekman et al., 2011; Fox & Reeves, 2015; Jags, 2016). This elucidates that there may be a risk that CGA, in itself, indicates assessments by the standardized test as gold standard may conflict with person-centredness (Gladman, Conroy, Ranhoff, & Gordon, 2016). However, the statements made by the American Geriatrics Society Expert Panel on Person-centred Care (Jags, 2016) claims that one should give higher priority to the choice of indicators focusing on quality of life, emerging from the person´s own values, than attaining specific health assessments that do not measure person-centred outcomes. Sidani and Fox (2014) describe the importance of care aimed to enhance the fit of care with patients’ characteristics and preferences. That is, tailoring treatments and services to the needs of the person. So, the first priority is to make a person-centred tailor-made CGA instead of focusing on assessing according to standardized instruments. Well-educated and experienced staff should have the ability to create a mutual person-centred story embedded in CGA who captures both the content of the instrument and revealing needs that are not covered by the instruments. That's why interprofessional education and training (Jags, 2016; Sidani & Fox, 2014) for the health and social care personnel is one essential element in the implementation of person-centred CGA.

Furthermore, the ideal image contrasted with the participating professionals' perception of how the assessment is performed in real life. Despite the ideal image, needs are not assessed if they cannot be met due to lack of resources or knowledge within an organization. Therefore, the available interventions direct the assessment, rather than the older person’s own priorities (Dunér & Nordström, 2006; Hasenfeld, 2010). Thus, a person-centred approach must be combined with appropriate and flexible services, matching individual needs. CGA provides a useful structure to care of the older population (Conroy & Turpin, 2016) but in order to implement person-centred CGA (Jags, 2016) one has to be aware that there are barriers for its implementation as this results shows. One important prerequisite to reach benefits and get over the barrier is an interprofessional team approach. The team is seen as critical in relation to respond to the person's needs, care and life goals, and there is research showing that CGA (Darby et al. 2017; SBU, 2014) is not effective when it is performed by individual professionals, but it is most effective when performed by interprofessional teams. However, bringing professionals together into the interprofessional team will not automatically lead to collaboration and integration of the participants as true partners (D’Amour, Ferrada-Videla, San Martin Rodriguez, & Beaulieu, 2005). In a fully integrated and coordinated care chain, the persons must be treated as equal partners in the team and person involvement must be promoted (Vestergaard & Nørgaard, 2018). As such, coordinated care chains with a person-centred approach have shown to be beneficial among frail older persons such as in improving activities of daily living (Eklund, Wilhelmson, Landahl, & Ivanoff-Dahlin, 2016).

Participants highlighted that needs may be hidden, particularly with regard to mental and cognitive functions. The result showed that tension can arise between the needs the person shows and the actual problems that arise in everyday situations and how these are assessed. The present study showed that some needs are clear and obvious, while others are hidden—even from those who are directly concerned. This hidden problem can be a threat to safety. Deficiencies in communication among professionals is one of the biggest dangers to safety for people in health and social care (Leonard, Graham, & Bonacum, 2004) implicating on an urgent need for developing a stable interprofessional vocabulary (Reeves et al., 2011). Safety for the person is a priority, and older persons are known to be at particular risk of adverse events (Long, Brown, Ames, & Vincent, 2013; Brennan et al., 1991), especially frail older people who may have other disabilities which in combination with cognitive and mental hidden problems can create more problems. Moreover, this can lead to the person not getting the care they need, which is also a safety risk (Banerjee & Macdonald, 1996). Health and social care are complex organizations and despite the fact that the staff is skilled, mistakes can occur. Effective teamwork and good communication can prevent these mistakes from having consequences for the patients or the staff (Leonard, Graham, & Bonacum, 2004). According to a review by Gordon et al. (Gordon, Darbyshire, & Baker, 2012) non-technical skills training to enhance patient safety must be highlighted.

The present study showed that needs assessment was affected by the collaboration around the patient and one key strategy to promote interprofessional care is to build and share a comprehensive knowledge of the patient and the plan (Hurlock-Chorostecki & McCallum, 2016). However, collaboration between those making the assessments and those working closely with the older people (e.g., nurse aids, home care, and family) seldom works. These people do not count as members of the team, or are not seen as valuable due to status or power differences (Fox & Reeves, 2015) even though they possess invaluable knowledge. The needs assessment process is conducted by professionals who have positions that are tied to expectations and requirements (Thylefors, 2012; Duner, 2013; Dunér & Wolmesjö, 2015; Thylefors et al., 2005), which gives them legitimate authority to determine needs (Fox & Reeves, 2015). To obtain a picture of the needs of the person that is as comprehensive and nuanced as possible, the people working closest to that person such as nurse aids and relatives must be understood and listened to. Westergaard et al. (Vestergaard & Nørgaard, 2018) pinpoint the importance of focusing on the hierarchic structures in order to promote interprofessional teamwork on equal terms. The person-centred approach (Ekman et al., 2011), with all people working around the person under assessment are given equal value, even if they do not possess the legitimate authority to determine the need, is therefore important.

Comprehensive geriatric assessment involves an interprofessional team approach (Caplan et al., 2004; Rubenstein et al., 1989), and it is vital that the different professional perspectives of their roles and responsibilities are clarified (Baker et al., 2011). Duner (2013) and Mur-Veeman, Eijkelberg, & Spreeuwenberg, (2001) showed that when implementing new ways of working, the professionals involved defended or enhanced their own interests. Core professional values come under pressure, especially if various groups have unequal power (Duner, 2013; Mur-Veeman et al., 2001), but good quality care and rehabilitation require collaboration (Gitlin, Hauck, Winter, Dennis, & Schulz, 2006). Successful collaboration is based on professionals’ desire to work together to provide better care (D’Amour et al., 2008). However, one has to a balance between interprofessional collaboration and time for professional autonomy as a way to prevent the polarization (Suter et al., 2009; Vestergaard & Nørgaard, 2018).

In this study, participating professionals expressed a wish to use each other’s expertise to perform assessments comprehensively and effectively. Instead, the reality (i.e., lack of resources and need to prioritize) resulted in polarization of their professional roles. Research has shown that the more integrative a team is, the higher the perceived efficiency (Thylefors et al., 2005). However, integrative teamwork is more resource demanding and might not be realistic throughout the care chain nor needed for all persons. Therefore, a balance between maintained professional identity (roles) and working in an integrative team is needed. To clarify teamwork, guidelines could include person-centred, team-based decision-making regarding the degree of integration the team should have.

Methodological considerations

Focus group discussion has been shown to stimulate interaction between group members and provide possibilities to diminish researcher control through a focus on the group and interactions between participants (Dahlin Ivanoff & Hultberg, 2006; Kitzinger, 1994). To stimulate discussion in a group, it is important that group members have something in common to discuss. In this study, 46 healthcare professionals who worked in Swedish clinical settings (e.g., hospitals, primary care, or municipal health and social care) participated in 10 focus groups.

Participants were selected primarily to illuminate the topic of interest (Krueger & Casey, 2015). It is possible that a greater number of participants might have affected the richness of content, as more diverse experiences might have been explored. However, the choice of venues for the focus group discussions helped to increase the richness of the content, as they were familiar and comfortable environments for the participating professionals. After 10 focus group discussions with a diversity of health professionals, the total richness of the content was considered satisfactory. However, it has to be kept in mind that some professions had two work directions (e.g., social workers) (Dunér & Wolmesjö, 2015).

Pre-existing groups are known to hinder interaction in focus group discussions. However, contrary to this view, other researchers claim that pre-existing groups may promote discussion as participants can relate to each other’s comments about the things that they have in common (Dahlin Ivanoff & Hultberg, 2006). In our study, we found that running the groups with people already known to each meant the interaction functioned well, and each participant expressed his or her opinion about the topic of discussion regardless of their previous collaboration.

Finally, as the focus group methodology is qualitative, we cannot make general conclusions and the results should be interpreted with caution. The method was based on discussions, which makes it impossible to comment on individuals. The strengths of the method lie in its ability to provide the opportunity to understand the way people view their own reality, and the researcher is given the opportunity to get closer to the data (Dahlin Ivanoff & Hultberg, 2006).

Conclusion

The health and social care personnel’s first priority is to make a person-centred tailor-made comprehensive geriatric assessment and not be bound to any particular instrument. This means the creation of a mutual story embedded in CGA in which all people around the person concerned are given equal value in order to create an as comprehensive and nuanced picture as possible of the needs of the person. This way of working places new demands on the healthcare personal, which is why educational training in person-centredness is one essential element in the implementation of CGA.

Clear guidelines need to be developed, stating which profession assesses what, when and how in order to ensure that person-centred needs are assessed. Health and social care are complex organizations, and it complicates communication. That is why interprofessional teamwork is important when conducting a person-centred CGA. Guidelines should include structures and procedures for how communication and collaboration within the team as well as between the organizations in order to perform a good person-centred CGA.

Conflict of interest

The authors declare that they have no conflict of interest.

Additional information

Funding

FAS centre: Aging and health. Center for capability in aging (AGECAP).