A gerontology nurse specialist role for high risk older people in the community

The study was a quasi-experimental design. An innovative intervention model was instigated within the primary healthcare setting comprising a screening tool to identify high risk older people with succeeding Gerontology Nurse Specialist (GNS) assessment and care coordination. The intervention model of care was initiated in two urban primary healthcare practices. Older adults aged 75 years or greater and enrolled in one of the primary healthcare practices were eligible for participation in the study. Older adults were excluded if they were residing in a residential care facility at the start of the study or if at the time they were receiving care under the local hospital-based GNS team. The Brief Risk Identification for Geriatric Health Tool (BRIGHT) was used to case find high risk older people. This screening tool is a straightforward 11 item self-administered survey. Each of the 11 questions has a “yes” or “no” answer and represents one count. The scores are summed with a total of three or higher indicating high risk of health and/or functional decline. The BRIGHT screen was posted, with a return self-addressed paid envelope, to older people who met eligibility criteria in the intervention group. If the posted BRIGHT screen was not completed and returned within two weeks, the GNS was to undertake follow-up phone calls to administer the BRIGHT over the phone. Subsequently, within one month of receiving the returned BRIGHT all older people deemed high risk (BRIGHT score of 3 or greater) were visited by the GNS in their own home where a Comprehensive Geriatric Assessment (CGA) was undertaken. This assessment would take approximately 1-1.5hrs. General Practitioners (GPs) could also directly refer older people they were concerned about to the GNS for assessment. The CGA was to be undertaken within two weeks of the returned BRIGHT screen, in the older person’s home at a mutually convenient time. A mixture of specific questions and standardised assessment tools were used to holistically and comprehensively assess the domains of physical health, functional ability, cognitive impairment, depression, pain, medications and social issues. Following this assessment, the GNS provided a summary of the older person’s current issues and developed an individualised intervention plan, this varied depending on personalised need, although often included education, referrals and ongoing GNS input and follow up. This summary was sent to the GP. The GNS was located within the primary healthcare organisation as well as integrating with hospital based specialist gerontology teams. These specialist teams provided the GNS with mentorship and increased expertise through peer clinical education sessions and weekly case conferences. The combination of primary and secondary care engagement afforded the GNS access to primary healthcare practice and hospital patient databases as well as the ability to simultaneously coordinate with community and specialist hospital services.