Development of an interdisciplinary single assessment form for use in integrated care setting

Background: A multidisciplinary integrated care service commenced in January 2017, consisting of a geriatrician, two clinical case managers, social worker, an occupational therapist and physiotherapist. The objective is to support older persons care across the healthcare continuum, from acute hospital to community, anticipating and meeting complex care needs as they arise. An essential piece in achieving this goal was to develop a standardised interdisciplinary Comprehensive Geriatric Assessment form which all members of the team were competent completing. Method(s): Mixed methods Delphi process was used. Weekly team meetings were held to identify relevant speciality priorities for inclusion. Review of commonly used assessment forms and screening tools for older persons was then carried out by the team. Through a number of additional meetings this information was amalgamated to compile a user friendly, patient centred assessment form based on current best practices. Each team member educated their colleagues on how to complete their discipline specific section of the form. The form was piloted for 4 months and then reviewed by the team. Result(s): The form was largely based on the InterRai single assessment tool (SAT). This multi-domain SAT has been recognised as a comprehensive screening tool for older persons and through extensive research was found to be most fit for purpose for Ireland (HSE). Key sections included detailed demographics, home environment and supports, medications, and measures of cognitive, physical, and functional wellbeing. Additional aspects not present in SAT but were considered of importance, such as the AD8 dementia screening instrument, were included. Conclusion(s): Feedback from team members reported that the form was user friendly, identified key issues and guided onward referral and actions. The form has also developed new areas of competency for each member of the team which in turn resulted in an improved service for older persons.

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