Home-based comprehensive assessment of rural elderly persons: the CARE project

Home-based comprehensive geriatric assessment (CGA) has been effective in urban areas but has had little study in rural areas. CGA involves medical history taking, a physical exam, and evaluation of functional status, mental status, cognitive status, gait and balance, medications, vision, extent of social supports, and home safety. We sought to develop and pilot a model of rural home-based CGA to determine whether successful urban models can be adapted to rural areas.

This study was a developmental demonstration project with qualitative and quantitative evaluation components of a home-based CGA model using a home health agency and a geriatrician participating from a remote location by teleconference. Findings and recommendations were relayed to patients, caregivers, and primary physicians. The population studied was elderly volunteers (N = 51) aged 75 years and older who did not have a terminal diagnosis or immediate plans to enter a long-term care facility. Survey instruments and focus groups were used with subjects, family members or caregivers, and physicians to generate refinements and outcome measures for the model.

Among the 51 patients undergoing CGA, Instrumental Activities of Daily Living dependency and balance and gait problems were highly prevalent. Means of 1.1 major problems and 4.9 nonmajor problems were identified per patient. Recommendations were implemented for 32% of major problems and for 35% of nonmajor problems. Primary physicians found recommendations for vaccination and home safety change helpful but were skeptical of physical examination findings by the nurse. Practitioners noted that this study resulted in several positive outcomes: (1) some subjects initiated regular clinic visits; (2) several visually impaired elders began services for the blind; (3) identification of gait and balance problems resulted in physical therapy treatment; and (4) identification of caregiver stress was addressed by social-work intervention. Potential further refinements of the model for rural home-based CGA were identified.

Home-based CGA identifies important problems of rural older adults. However, modifications are still needed to create a truly effective process.