Comprehensive geriatric assessment (CGA), continuity, and coordination

In the page titled Frailty management across the frailty spectrum, we presented an overview of population health management across the whole frailty trajectory.

As frailty progresses into moderate and severe frailty, care increasingly depends on managing complexity across multiple professionals, organisations, and services over time.

This is where Comprehensive Geriatric Assessment (CGA), continuity of care, and coordinated multidisciplinary working become central to effective frailty management.

The following sections explore each of these components in turn, including the evidence supporting their role in improving outcomes for people living with frailty.

Comprehensive Geriatric Assessment (CGA) is widely recognised as the gold standard model for managing moderate and severe frailty.

It is a multidimensional, multidisciplinary process used to assess and coordinate care across medical, functional, psychological, and social domains, leading to a personalised care and support plan developed with the individual and those important to them, including family members and carers where appropriate.

There is a substantial body of evidence demonstrating that Comprehensive Geriatric Assessment improves outcomes for people living with frailty. Studies have shown that people receiving CGA are more likely to remain alive and living at home, maintain function, and avoid institutional care compared with standard care approaches (1,2).

Continuity of care describes the ability of care and decision-making to develop over time through ongoing relationships, shared understanding, and cumulative clinical knowledge.

For people living with frailty, continuity is particularly important because relatively small changes in mobility, cognition, function, or social support may represent significant deterioration.

Continuity allows these changes to become visible earlier within the context of an ongoing relationship rather than isolated episodes of care.

There is a consistent body of evidence demonstrating that continuity improves outcomes. Studies have shown that when patients experience continuity of care, they are more satisfied with their care, receive higher quality care, experience fewer emergency department attendances and hospital admissions, and have improved long-term outcomes (3,4,5).

Coordination describes how multiple professionals, organisations, and services work together around the individual to deliver joined-up care over time.

People living with moderate and severe frailty often require support from multiple contributors simultaneously, including general practice, community and therapy services, geriatric medicine, social care, mental health services, urgent and acute care teams, ambulance services, care homes, and VCFSE organisations supporting people within the community.

Coordination is not about repeatedly moving people between services through referral and handover processes. It is about services organising themselves around the individual so that care feels joined-up, continuous, and coordinated rather than fragmented across organisational boundaries.

Evidence consistently demonstrates that coordinated multidisciplinary care improves outcomes for people living with frailty by reducing fragmentation, supporting earlier intervention, and improving continuity over time (6,7).

The evidence supporting Comprehensive Geriatric Assessment, continuity, and coordinated multidisciplinary care is strong.

However, the current healthcare landscape often struggles to operationalise these principles consistently across neighbourhood systems.

Comprehensive Geriatric Assessment is frequently reduced to isolated assessment activity completed at a single point in time rather than functioning as a continuous coordinated process.

At the same time, care for people living with frailty is often distributed across multiple organisations, teams, referral pathways, and IT systems. Information may be fragmented between services, waiting lists are held separately, referral thresholds vary, and teams often work within relatively narrow organisational or professional boundaries.

As a result, services may fail to recognise deterioration because signals are encountered as isolated events across different services. Important clinical and longitudinal knowledge about the person is lost between episodes of care.

For people living with frailty, fragmented care and one-off assessment approaches can lead to delayed intervention, avoidable deterioration, loss of independence, and avoidable hospital admission over time.

At Target Health Solutions, we believe that for older people with moderate and severe frailty, effective population health management requires neighbourhoods to provide:

• Continuous Comprehensive Geriatric Assessment
• Continuity of care over time
• Coordinated multidisciplinary working
• Shared digital infrastructure
• Ongoing monitoring and review
• Integrated Neighbourhood Team delivery

The following sections explore how these core principles can be operationalised through frailty coordination hubs, Integrated Neighbourhood Teams, shared digital infrastructure, and longitudinal monitoring.

For a deeper exploration of Comprehensive Geriatric Assessment, continuity, and coordination, including supporting evidence and operational examples, see NHS Frailty Paradox Part 5.

1. Ellis G, et al. Comprehensive geriatric assessment for older adults admitted to hospital. Cochrane Database Syst Rev. 2017 Sep 12;9(9):CD006211. doi: 10.1002/14651858.CD006211.pub3.
2. Attwood D, et al. Does proactive care in care homes improve survival? A quality improvement project. BMJ Open Qual. 2024 Jun 4;13(2):e002771. doi: 10.1136/bmjoq-2024-002771.
3. Barker I, et al. Association between continuity of care in general practice and hospital admissions for ambulatory care sensitive conditions: cross sectional study of routinely collected, person level data. BMJ 2017; 356:j84 doi: https://doi.org/10.1136/bmj.j84
4. Pereira Gray D., et al. Continuity of care with doctors-a matter of life and death? A systematic review of continuity of care and mortality. BMJ Open. 2018 Jun 28;8(6):e021161. doi: 10.1136/bmjopen-2017-021161.
5. Baker R, et al. Exploration of the relationship between continuity, trust in regular doctors and patient satisfaction with consultations with family doctors. Scand J Prim Health Care. 2003 Mar;21(1):27-32. doi: 10.1080/0283430310000528.
6. Hendry A, et al. Integrated Care Models for Managing and Preventing Frailty: A Systematic Review for the European Joint Action on Frailty Prevention (ADVANTAGE JA). Transl Med UniSa. 2019 Jan 6;19:5-10. PMID: 31360661; PMCID: PMC6581495.
7. Hébert, R. et al. ‘Impact of PRISMA, a coordination-type integrated service delivery system for frail older people in Quebec (Canada): a quasi-experimental study’, Journals of Gerontology Series B, 2010 65B(1), pp.107–118. DOI: 10.1093/geronb/gbp027.