Comprehensive Geriatric Assessment (CGA)

A holistic, evidence-based approach to improving outcomes for older people

The Comprehensive Geriatric Assessment (CGA) is an internationally recognised, multidimensional process that brings together medical, functional, psychological and social information to build a complete picture of an older person’s health. When digitised, the CGA becomes a powerful enabler of coordinated, person-centred care - supporting better decision-making, reducing risk and improving quality of life.

Graphnet’s digital CGA will be embedded directly into our population health management platform and crucially, linked to falls data. It provides, integrated assessments that can be accessed across settings - primary, community, acute and social care, ensuring every professional works from the same, up-to-date information, and patients and carers alike do not have to continually repeat information

Why CGA Matters

Older adults living with frailty or multimorbidity conditions have some of the most complex care needs within any health and care system. Evidence from the British Geriatrics Society and multiple international studies shows that CGA completion and use consistently leads to:

• Reduced unplanned and unnecessary hospital admissions
• Lower fall rates, particularly in acute settings
• Fewer admissions to long-term care facilities
• Lower incidence of delirium
• Improved recovery after surgery
• More appropriate medication use and deprescribing

CGA is recognised as a key component of modern, integrated care models and aligns closely with the objectives within the NHS Long Term Plan for proactive, personalised, out-of-hospital care.

A Digital CGA Designed for Integrated Care Systems

Graphnet’s CGA brings clinical, functional and social information into one secure digital workflow. Whether a person is at home, in hospital or in a care setting, professionals can access the same comprehensive view - supporting earlier identification of risk, smooth transitions of care and shared decision-making.

Key Features

A unified assessment workflow

• Covers physical and cognitive health, falls and mobility, mental wellbeing, nutrition, oral health, functional abilities, medication review and more
• Integrates ReSPECT and EPaCCs (where recorded) within the same workflow
• Surfaces relevant GP data and clinical scores automatically    

Intelligent clinical scoring

The CGA automatically displays the latest validated assessments, including:

• eFI (electronic Frailty Index) score
• Clinical Frailty Scale (Rockwood)
• Malnutrition Universal Screening Tool (MUST) score
• Johns Hopkins ACG® Patient Need Group (PNG), with colour-coded risk indicators

This ensures clinical information is available as early as possible and presented consistently across teams.

Shared, coordinated care planning

• Multidisciplinary teams can collaborate around the same problems, plans and actions
• Information is standardised, reducing duplication and variation in practice
• Supports ongoing review as an individual’s needs change over time

Benefits for Clinicians

Faster, more efficient workflows

• Streamlined assessment creation and review
• Rapid access to relevant information
• Early visibility of risk markers such as frailty, falls or medication concerns

Standardised and accurate assessments

• Reduced variability between assessors
• Consistent use of validated clinical tools
• Up-to-date scores automatically surfaced

Improved clinical decision-making

• Clear visibility of health trends over time
• Earlier identification of cognitive, physical or functional decline
• Robust information to support proactive interventions

Truly coordinated multidisciplinary care

• Seamless information sharing across geriatricians, nurses, AHPs, pharmacists, social care and voluntary sector teams
• Shared care plans with follow-up actions
• Reduced duplication of history-taking and assessments

Benefits for Care Teams

The Comprehensive Geriatric Assessment has been shown to improve patient outcomes and optimise healthcare services across a range of care settings:

1. Primary care:The CGA helps identify individuals at risk due to frailty and/or multiple comorbidities, enabling early intervention, improved care coordination, reductions in hospital admissions and functional decline. Medication reviews in the CGA have also been associated with reduced mortality.
2. Community settings: The CGA is linked to reductions in physical frailty and unplanned hospital admissions.
3. Acute hospital settings: According to the British Geriatrics Society, the CGA has its strongest evidence base in acute care [1], demonstrating significant reductions in falls and admissions to long-term care facilities.
4. Emergency departments: Use of the CGA by Acute Frailty Teams and Same Day Emergency Care (SDEC) services has been associated with lower admission and re-admission rates.

The Comprehensive Geriatric Assessment should be recognised as a key component of any integrated care system’s strategy for developing effective, patient-centred services for the populations they serve.

Benefits for Older Adults, Families and Carers

Person-centred, holistic care

Older people feel understood across all aspects of their health—physical, emotional, social and cognitive. Care plans reflect their goals, preferences and capabilities.

Clear understanding of their health

• Better insight into risks, strengths and conditions
• Accessible explanations of clinical recommendations

Improved quality of life

• Greater independence and daily functioning
• Fewer preventable incidents such as falls or medication issues
• Reduced hospital visits and admissions

Better coordinated care

• No need to repeat their story or undergo duplicate tests
• All professionals working from the same information

Support for families and caregivers

• Clear information and practical guidance
• Ability to take part in discussions and planning
• Greater reassurance and confidence in the care being provided

Driving Better Population Health Outcomes

The digital CGA is an essential component of proactive, integrated care for older adults. By giving clinicians a richer, clearer picture of an individual’s needs and enabling coordinated action across services, it helps improve outcomes while supporting a more sustainable NHS and social care system.

Sources:
[1] https://www.bgs.org.uk/CGA