Comprehensive Geriatric Assessment for Nursing Home Residents at Risk of Death Within 6 Months

Background Nursing home residents are a vulnerable group with high morbidity and limited life expectancy. End-of-life planning is highly important and sometimes inadequately addressed in this group. We sought to implement and evaluate a screening tool and comprehensive geriatric assessment (CGA) process for identifying and supporting nursing home residents at high risk of death within 6 months. Methods Four nursing homes screened their residents and identified those meeting predefined clinical risk criteria for mortality within 6 months. These were weight loss, pressure ulcers and recurring infections. Patients identified were referred to a Gerontology Outreach team for Comprehensive Geriatric Assessment. Changes in documented care preferences, healthcare utilization, and mortality were tracked. Results Of 124 residents assessed, 25% had >50% predicted risk of death within 6 months. We recommended medication changes in 40% of the group and15% were referred onwards for multidisciplinary team input. Following engagement with resident and families the prevalence of DNAR orders increased from 68% to 79%. Fewer people wanted full medical intervention 20% from 33%, and fewer wanted limited intervention 24% from 35%. More people wanted comfort care increased from 29% to 48% and palliative care; increased from 3% to 8%. In the year following the intervention hospitalizations from the 4 nursing homes decreased by 3%. Six-month mortality was 46% with most of these (86%) occurring in the nursing home. Most of the 34 hospital admissions (85%) were in people who had expressed a preference for further hospital care. Conclusion CGA significantly improved alignment of care with resident preferences and reduced unnecessary hospital admissions. The tool is effective and potentially scalable for broader implementation.