Effectiveness of Comprehensive Geriatric Assessment to improve outcomes for Older PeoplE having hip and knee replacement surgery (COPE).

Comprehensive Geriatric Assessment (CGA) is the provision of care by a multidisciplinary team (MDT) pre- and post-operative, to identify medical, social and functional needs of older people and develop and execute an integrated/coordinated care plan that centres around the older person and their values, preferences and goals. For the purposes of the COPE trial the CGA will be provided to patients undergoing an elective total hip replacement (THR) or knee replacement (TKR). Comprehensive Geriatric Assessment Peri-operative CGA-based models of care can be broken down to three key components to improve outcomes: active pre-operative assessment involves diagnosing and treating medical conditions and addressing modifiable risk and lifestyle modification prior to surgery (such as nutrition, exercise), a pre-operative management care plan for the MDT, and post-operative review to actively monitor and prevent complications and provide early detection and management of problems such as dehydration, delirium, infections and cardiac events. Pre-operative assessment The pre-operative assessment will include assessment of: Joint pathology Frailty Existing medical conditions, severity, management, ability and plan to optimise. Medical screening for undiagnosed conditions Medication reconciliation Social and functional history Legal factors including substitute decision-maker, Powers of Attorney, Advance Care Planning documentation. Examination - physical and cognitive Routine pathology and ECG, and consideration of testing for cardiac, pulmonary and sleep abnormalities Identification of patient perceptions, values and preferences Postoperative risk quantification, monitoring and mitigation plan, and communication with patients and family/carers and the multidisciplinary team Whilst some hospitals may provide prehabilitation to patients undergoing elective THR or TKR (such as exercise, nutrition, psychology), CGA is a broader, multidomain model that crucially involves a dedicated service that provides person-centred optimisation and shared decision making. Pre-operative management care plan Synthesis of assessment findings undertaken by a health care professional, specially trained in the delivery of the CGA intervention (a COPE clinician) and who will coordinate the MDT. The MDT and the COPE clinician, decide collaboratively with the patient, using a shared decision-making model, whether to a) to pursue surgical intervention or b) to not pursue surgical intervention after considering the risks and benefits. If the patient decides to pursue surgery, the COPE clinician will coordinate with the surgical team the pathway to surgery maximising optimisation targets to be met (addressing modifiable patient risks in the context of the procedure) and avoiding unnecessary delays. A pre- and post-operative management plan will be developed and discussed with the patient and the multi-disciplinary care team, and the patient will be provided with specific information to prepare them for surgery. If the patient decides not to pursue surgery, the COPE clinician will provide the patient with alternative or additional management options. Post-operative review and prevention and treatment of complications The geriatrician, anaesthetist and surgical team and, when required, intensivist determine the immediate post-operative management based on patient risk assessment, intra-operative and institutional factors and provide an appropriate handover to the relevant MDT members who have input in the post-operative period. The COPE clinician and MDT collaborate to anticipate, prevent, detect and respond to complications in the patient in the post-operative period. The post-operative review and management includes (but is not limited to): Pain management Management of wound, postoperative orders Proactive prevention, screening for medical complications and management on occurrence Early mobility and progression of mobility status Review of functional status as mobility progresses Discharge planning Prior to discharge the COPE clinician will coordinate a post-discharge management plan to ensure the patient’s discharge from the acute care setting is well coordinated. COPE clinicians will be assigned by the hospital sites. Geriatricians have a high level of expertise in CGA and are key to effectively delivering CGA. Geriatricians will therefore be the first choice to deliver the intervention. However, in case a hospital site does not have geriatricians available to deliver this intervention, the following clinicians can also be employed as COPE clinicians: A Physician with older adult experience A Nurse Practitioner with experience treating acute older adults The MDT will include (but is not limited to) health care professionals from medical, nursing, allied health (including all or a combination of physiotherapy, occupational therapy, dietetics, speech pathology, social work), and pharmacy. The exact make-up of the MDT will be dependent on each individual hospital site and will be developed as part of the implementation planning and contextual adaptation phase of the project. Pre-operative assessment will be completed between 4 weeks-3 months prior to booked elective surgery. Post-operative assessment by the COPE clinician will commence within 48 hours of surgery. The pre-operative assessment will be undertaken as part of an outpatient clinic (to be determined at each site), through a combination of face-to-face and/or telephone-based contact. The post-operative assessment will be undertaken in the acute hospital setting. Once the patient is discharged from the acute hospital setting, they will be discharged from the intervention.