In the UK’s autumn and winter months, health and care systems begin to see familiar seasonal pressures. Respiratory illnesses rise, mobility becomes more difficult, and older people living with frailty or multiple long-term conditions face a greater risk of deterioration.

For many older patients, this can mean increased falls, infection, or worsening chronic conditions. For services across primary care, community teams, and hospitals, it often leads to rising emergency admissions – placing more pressure on discharge pathways. 

Brandon Newman, Graphnet's Clinical Workflow Lead and operational paramedic: “If we manage older patients appropriately, we could help reduce hospital admissions and, therefore, improve discharge pathways.

“Patients who are in hospital and struggling to be discharged for whatever reason, can become sarcopenic, (lose their muscle mass) and become even harder to discharge. It just becomes a cycle which is exacerbated in the colder months.” 

Managing these risks requires not just reactive care, but a coordinated, proactive approach that identifies vulnerability early and supports people before a crisis occurs.

Enter the Comprehensive Geriatric Assessment (CGA), a structured approach to understanding and managing the complex needs of older people living with frailty. The CGA can help services anticipate risk, coordinate multidisciplinary support, and manage winter demand more effectively across the health and care system. If a patient undergoes a CGA during admission, then this information is available through the Graphnet Shared Care Record. This pan-ICB solution supports community teams, so a range of healthcare workers from GPs to paramedics can see the assessments that have taken place and key goals for the patient. This further supports the NHS long term plan from hospital to community neighbourhood working model.

What is a Comprehensive Geriatric Assessment (CGA)?

The CGA is a structured, multidisciplinary approach to assessing the health and well-being of elderly people. It is a coordinated process bringing together clinical expertise from different disciplines to understand the full picture.

Rather than focusing on a single condition or episode of care, CGA considers a range of interconnected factors that influence a person’s ability to live safely and independently.

These typically include: 

• Medical status and long-term conditions
• Medicines review and optimisation
• Functional ability, mobility, and risk of falls
• Cognition, mood, and psychological well-being
• Social circumstances, carers, and practical support
• Home environment and wider safety factors

CGA is usually delivered by a multidisciplinary team that may include geriatricians, nurses, pharmacists, physiotherapists, occupational therapists, and social care professionals.

Together, they develop a coordinated and personalised care plan that reflects both clinical needs and the individual’s day-to-day living circumstances.

Importantly, CGA is not simply a single assessment or form to complete, but an ongoing process that evolves as a patient’s needs change.

How CGA supports winter resilience for people living with frailty

Winter demand reveals the pressure points in care pathways. Health can deteriorate quickly in cold, damp weather, and when services are busy, even small gaps in information can slow decision-making.

The CGA helps address this by focusing on several key areas that support earlier intervention and better coordinated care:

1) Earlier identification of frailty 
Most admissions don’t start as emergencies. They begin with smaller warning signs such as reduced mobility, appetite changes or missed medications.

The CGA supports earlier identification through structured review in primary care, community services, and care homes. Risk stratification can help teams prioritise who needs proactive input, but the real value comes from combining clinical information with social context. A person may look stable on paper and still be at high risk if they live alone, struggle with stairs, or have limited support. The Patient Needs Group (PNG) is a way of categorising older patients based on the complexity of their health and social care needs. Adding this into a Comprehensive Geriatric Assessment (CGA) strengthens how targeted, efficient, and holistic the assessment is. The addition of the Patient Needs Group (PNG) enhances early recognition of admission and mortality risk, prompting timely optimisation reviews and supporting preventative clinical decision‑making.

By identifying frailty earlier, services can intervene before deterioration reaches urgent care.

2) Avoidable admission 
When urgent care teams lack context, escalation becomes the safer default. A CGA-informed plan changes that. It can give clinicians rapid access to a patient’s baseline function, key risks, current medications, and agreed escalation pathways.

That does not mean admissions are avoided at all costs. It means decisions are better informed, and alternatives such as same-day emergency care, community response, or short-term support can be used more confidently.

Medication review also matters here, because polypharmacy and adverse effects often contribute to falls, confusion, and instability during winter surges.

3) Safer, faster discharge 
Discharge delays often come down to missing pieces. A person’s home environment is unclear, therapy needs are not yet agreed, social support is not fully coordinated, or key information is trapped in one organisation’s notes.

A CGA improves this by putting a holistic picture in place early. When the assessment and care plan are accessible across teams, duplication reduces and handovers become more reliable. That can speed up pathway decisions and improve safety, particularly when community services are under pressure.

4) Reduced readmissions 
Older people living with frailty often move between services, sometimes quickly. Without continuity, the system can unintentionally reset each time the person is seen, repeating questions, missing changes, and losing track of agreed plans.

A CGA supports follow-up and continuity by keeping the care plan visible and up to date across primary care, community teams, acute services, and social care. That shared visibility supports earlier reviews after discharge and more consistent management, which can reduce avoidable returns to the hospital.

5) Population health analysis
The CGA can also be used as a data analysis tool to help identify at-risk people and target them early. Moving health care from treatment to prevention means fewer people are admitted. CGA data can help at a population level to find connections between things like fuel poverty or location and certain conditions to provide more targeted early intervention. 

The role of digital enablement

CGA can be carried out without digital tools but applying it consistently across an integrated care system becomes much harder if assessments and care plans are not easily recorded, shared and updated.

Instead of information being stored in separate systems or repeated across services, a digital CGA creates a single, accessible view of an individual’s health, needs and risks.

In practice, digital support for a CGA helps by enabling:

• Structured assessment templates, ensuring consistent and comprehensive evaluations across teams
• Shared care plans, so multidisciplinary teams can work from the same information
• Real-time updates, allowing changes in a patient’s condition to be visible quickly
• Integration across primary, community, acute and social care services, supporting coordinated care across settings
• Population-level insights, helping systems understand patterns of frailty, falls and risk within their communities

Graphnet’s digital CGA is designed to support this kind of coordinated approach. Embedded within its population health management platform, it brings together medical, functional, psychological and social information in a single workflow.

Clinicians can access relevant GP data, validated frailty and risk scores, and shared care plans in one place, helping teams identify risk earlier and coordinate support more effectively.

Crucially, this shared view means professionals across different organisations can work from the same up-to-date information. It reduces duplication, supports smoother transitions between services, and ensures that older people and their carers do not need to repeatedly explain their history as they move through the system.

Practical application during winter

Many winter response models rely on quick coordination and access to shared information. In practice, CGA often underpins these approaches, even if it is not always explicitly described that way.

Examples include:

• Frailty hubs, where multidisciplinary teams assess and stabilise patients quickly, aiming to avoid unnecessary admission
• Same Day Emergency Care, where rapid assessment and treatment support safe alternatives to overnight stays
• Virtual wards, where hospital-level oversight is combined with home-based support for suitable patients
• Community frailty services, offering proactive review, therapy input, and medicines optimisation
• Care home support models, where coordinated input helps reduce ambulance conveyance and avoidable transfers

In each case, a digitally accessible CGA plan can reduce time spent reconstructing history and increase confidence in next steps.

Building sustainable winter resilience

Winter demand is predictable, but the pressures it creates can be managed more effectively with the right approach.

A CGA provides a patient-centred framework for proactive frailty management, and the evidence base supports its role in improving outcomes for older people. Digital infrastructure then determines whether the CGA stays localised or becomes a system-wide capability that teams can rely on during peak periods.

For Integrated Care Systems, the combination matters. Shared, actionable care planning supports better coordination now, and it also builds maturity in how the system manages frailty over time. The outcome is not simply fewer admissions, although that is important. It is better care that protects independence, reduces avoidable harm, and supports safer decisions when services are under strain.

To learn more about how Graphnet supports CGA and shared care planning across health and care settings, speak to our team today.