THE PROCESS OF CARE IN PREVENTIVE IN-HOME COMPREHENSIVE GERIATRIC ASSESSMENT

OBJECTIVES: To describe the process of care of a program of in-home co mprehensive geriatric assessment (CGA) and to determine: (1) if there are major findings in all domains of CGA (medical, functional, mental health, and social/environmental), (2) if there is a continued clinica l yield when CGA is repeated annually, and (3) factors that affect pat ient adherence with recommendations from CGA. DESIGN: Descriptive pros pective study of subjects allocated to the intervention group of a 3-y ear randomized trial of preventive in-home CGA. SETTING: Homes of part icipants living in an urban setting. PARTICIPANTS: Persons aged 75 yea rs or older and living at home who received the intervention (N = 202 subjects, mean age 80.8 years, 70% female, 95% white, 64% living alone ). INTERVENTION: Annual in-home CGA and quarterly home visits by geron tologic nurse practitioners for 3 years. MEASUREMENTS: Detailed data w ere collected prospectively on clinical problems detected by CGA, and specific recommendations were made for these problems using an instrum ent developed explicitly for this project to study the CGA process. Su bject adherence with these recommendations was also recorded. RESULTS: Major problems were identified in all domains of CGA; the most common problems were medical. In the first year, 76.7% of subjects had at le ast one major problem identified that was either previously unknown or suboptimally treated. One-third of subjects had additional major prob lems identified during the second and third years. A constant number o f therapeutic and preventive recommendations was made each year (11.5 per subject annually). Subject adherence varied by type of recommendat ion (ANOVA, F = 108.4, P <.001); adherence was better for referrals to a physician than for referrals to a non-physician professional or com munity service or for recommendations involving self-care activities ( Scheffe's test, P <.001). CONCLUSION: In these community-dwelling olde r people, there was a continued yield of problems identified and recom mendations made when CGA was repeated annually for 3 years, supporting the practice of repeat CGA in older people in the community. Subject adherence with recommendations from CGA varied by type of recommendati on, but further work is needed to determine additional factors that af fect this adherence and to determine the association between the yield of CGA (i.e., problems identified, recommendations given and adherenc e with these recommendations) and important clinical outcomes.