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

Background This study explored the clinical and process outcomes of older adults at risk of or living with frailty who received an interdisciplinary Comprehensive Geriatric Assessment (CGA) in the community. Methods This prospective cohort study recruited older adults aged≥75 who were screened for frailty and referred to one of three CST-OP hubs in the Mid-West of Ireland by their GP. Follow-up assessments were conducted via telephone by an independent assessor at 30- and 180-days. The primary outcome was functional status. Secondary outcomes included primary healthcare use, secondary healthcare use, nursing home admission, health-related quality of life (HRQoL), patient satisfaction and mortality. Results A total of 303 participants (mean age=83.2 years) were recruited. Incidence of 30- and 180-day functional decline was 26.4% and 33.7% respectively. The majority of older adults who availed of community-based CGA maintained functional independence up to 6-months post index visit. At 30-days, the mortality rate was 1.0%, Emergency Department (ED) presentation 6.9%, hospitalisation 6.6% and nursing home admission 4.0%. HRQoL significantly improved at 30- and 180-days. There was a significant improvement in HRQoL, F(2,542)=13.8, p<0.001, η2=0.5. The presence of frailty was a significant predictor of adverse outcomes. Conclusion Community-based CGA results in favorable health outcomes including HRQoL among community dwelling older adults. Community-based CGA may also mitigate against potentially avoidable ED presentations and hospitalisations. Use of the Clinical Frailty Scale is recommended to predict the risk of functional decline, increased rates of mortality, NH admission, hospitalisation or ED presentation at 30- and 180-days among community -dwelling older adults.