SPHeRE Scholar Christina Hayes
My name is Christina Hayes, and I am a Physiotherapist and SPHeRE PhD scholar based at the University of Limerick. My PhD focusses on developing an evidence-based and stakeholder informed model of integrated care for older adults living in the community, which is supervised by Professor Rose Galvin, Dr Christine Fitzgerald and Associate Professor Molly Manning.
Where are we now?
Population ageing is occurring at an unprecedented rate worldwide. Ireland has seen a 23.2% increase of adults aged 65 years and over since 2018 (1). By 2041, it is estimated that there will be almost 1.4 million adults aged 65 years and over in Ireland, representing an increase from 11.6% (2011) to 22.4% of our overall population (2). Furthermore, by 2100, over a third of the European population will be over 65 (3). While this increased longevity is positive, later life is often characterised by poor health (4). The question is, how are health and social care organisations adapting how health services are delivered to the ageing population?
The World Health Organization (WHO) has acknowledged that integrated care strategies in the community are the best approach in response to the delivery of complex care to enable older adults so that they experience the best possible outcomes (5). Integrated care is defined as ‘services that span the care continuum, are integrated within and among the different levels and sites of care within the health care and long-term care systems (including within the home), and are integrated according to people’s needs throughout the life course’ (World Health Organization (5) p.6).
For many older adults, their first point of contact with the health service is through their General Practitioner (GP) (6). We collated the evidence in relation to the effectiveness of interdisciplinary care in the community, inclusive of care by GPs in a recently published systematic review (7). Care provided by these interdisciplinary teams leads to better outcomes for older adults, with significant improvements in functional ability, number of hospitalisations and participant satisfaction with care from 12-36 months follow-up.
Despite the increasing need for integrated care, a lack of clarity regarding the concept has led to a variation in delivery across health systems and settings. The Integrated Care Programme for Older People in Ireland are leading out on the delivery of coordinated and integrated care for older adults that allows them to access care closer to home (8). One such approach is the establishment of community specialist teams for older people (CST-OP) whereby experienced multidisciplinary team (MDT) members from medical, nursing, pharmacy and health and social care professions offer prompt comprehensive geriatric assessment (CGA) in the community to older adults. We conducted the first national study that characterises the process, clinical and patient-reported outcomes of older adults over a 6-month period who are referred to one of the three CST-OP hubs in the Mid-West of Ireland by their GP and receive CGA (Hayes et al. 2024, in press). A total of 303 participants were recruited in this study. The mean age of participants was 83.23 years (Standard Deviation (SD) = 5.77) with females representing 67.7% of the total population. The prevalence of frailty in this group was 55.4% (n=168). Older adults living with frailty experienced increased risk of functional decline, increased rates of mortality, NH admission, hospitalisation or ED presentation at 30 and 180 days. With regards to functional status, despite the pre-frail/frail presentation of older adults to the CST-OP hub, functional status was maintained at 30 days. There was however a significant reduction in functional status at 180 days. Results also showed a significant improvement in health-related quality of life (HRQoL) between index visit and 30-days and between index visit and 180-days.
As CGA is an integral part of care delivered to community dwelling older adults, we conducted the first evidence synthesis exploring community-dwelling older adults’, caregivers’ and healthcare professionals’ (HCP) experiences of CGA in the primary care and out-patient (OPD) setting (9). Findings demonstrate that CGA in a home-based or OPD setting allows for a holistic and integrated approach to care for community-dwelling older adults while increasing patient satisfaction and accessibility of healthcare. The home environment was also reported as enhancing the CGA experience among stakeholders.
Although CGA has become a central pillar in health care delivery models for older people, the effectiveness of such models across settings is unclear. A Cochrane review published in 2022 including 21 randomised controlled trials (RCTs) demonstrated that CGA provided to frail older adults in the community setting (participant’s home, general practice or community-based clinic) reported little to no impact on older adults’ clinical or process outcomes (10). However, findings from our updated systematic review and meta-analysis that examined the effectiveness of domiciliary-based CGA compared with usual care among community-dwelling at-risk older adults resulted in improved functional status at 6-months to 24-months, at 12-months and at 24-months, an increased HRQoL at 6-24 months and 12-months, a reduction in mortality at 36-months, a reduction in hospitalisations at 6-36 months and improved patient satisfaction with care at 6-12 months (11).
Where do we go from here?
Further primary research examining the effectiveness of domiciliary-based or a hybrid model including domiciliary-based and OPD/’hub-based’ based intervention in the community versus ‘hub-based’ care for older adults should be conducted.
References
- Central Statistics Office of Ireland. Population and Migration Estimates, April 2024. Dublin, Ireland; 2024.
- TILDA. The Irish Longitudinal Study on Ageing. Dublin, Ireland; 2023.
- European Commission. Population projections in the EU. 2023.
- World Health Organization. Ageing and Health. Geneva; 2022.
- World Health Organization. INTEGRATED CARE FOR OLDER PEOPLE Realigning primary health care to respond to population ageing. Geneva; 2018.
- O’Dowd T, Ivers J-H, Handy D. A future together building a better GP and primary care service. 2017.
- Hayes C, Manning M, Fitzgerald C, Condon B, Griffin A, O’Connor M, et al. Effectiveness of Community‐Based Multidisciplinary Integrated Care for Older Adults with General Practitioner Involvement: A Systematic Review and Meta‐Analysis. Health & Social Care in the Community. 2024;2024(1):6437930.
- ICPOP Steering Group. Making a start in integrated care for older persons a practical guide to the local implementation of integrated care programmes for older persons. 2017.
- Hayes C, Fitzgerald C, O’Shaughnessy Í, Condon B, Leahy A, O’Connor M, et al. Exploring stakeholders’ experiences of comprehensive geriatric assessment in the community and out-patient settings: a qualitative evidence synthesis. BMC Primary Care. 2023;24(1):274.
- Briggs R, McDonough A, Ellis G, Bennett K, O’Neill D, Robinson D. Comprehensive Geriatric Assessment for community‐dwelling, high‐risk, frail, older people. Cochrane Database of Systematic Reviews. 2022(5).
- Hayes C, Amanuel Yigezu, Sarah Dillon, Christine Fitzgerald, Molly Manning, Aoife Leahy, et al. Home-based comprehensive geriatric assessment for community-dwelling, at-risk, frail older adults: A systematic review and meta-analysis. Journal of the American Geriatrics Society. 2025.