Older people with frailty, multiple long-term conditions or complex care needs often interact with a wide range of services at different points in their care journey. Without a shared understanding of the person’s needs, risks and goals, however, care can quickly become reactive, duplicated or fragmented. Important changes may be missed, professionals may only see part of the picture and families can find themselves repeating the same information across multiple services.

For health and care professionals, building a shared understanding of the person’s needs, risks, goals and circumstances is the biggest challenge. Then turn that understanding into coordinated action.

Graphnet’s Comprehensive Geriatric Assessment (CGA) supports this process by helping teams bring complex information together. But assessment alone is not enough. CGA creates real value when assessment insight is translated into coordinated action through shared care planning, follow-up and ongoing review.

CGA is recognised as a holistic, multidisciplinary process that considers medical, psychological, functional, social and environmental factors to develop an individualised care plan. Importantly, it’s not intended to function as a one-off assessment completed in isolation, but rather as an ongoing process of planning, coordination and reassessment that supports proactive care over time.

 

Why CGA matters for older people with complex needs

Older people’s needs are rarely isolated. A fall may be linked to medication, mobility, cognition, nutrition, home environment or reduced social support. Increasing frailty may affect confidence, independence and mental wellbeing alongside physical health. Dementia, poor nutrition or sensory impairment can each influence how safely someone manages at home.

CGA helps teams understand these interconnected factors as a whole picture, rather than treating issues separately.

A comprehensive assessment may include consideration of:

• Physical health
• Cognitive health
• Mental wellbeing
• Mobility, balance and falls risk
• Medication and polypharmacy
• Nutrition and oral health
• Functional ability
• Social and environmental factors
• Personal goals and preferences

The British Geriatrics Society (BGS) describes CGA as a multidisciplinary process that considers medical, psychological, functional, social and environmental factors to develop an integrated and individualised care plan. This broader perspective is particularly important for older people with frailty or complex needs because risks often emerge gradually across multiple areas rather than through a single event or diagnosis.

Brandon Newman, Paramedic and Clinical Workflow Lead at Graphnet Health, describes CGA as an approach that brings together multiple overlapping syndromes and risk factors, including frailty, dementia, mobility concerns, nutrition and wider social issues. 

He also highlights the importance of multidisciplinary contribution across the care pathway, with professionals from geriatrics, therapy, nutrition and community care all helping build a more complete picture of the person’s needs. 

By combining insight from geriatricians, nurses, pharmacists, allied health professionals, social care and community services, CGA can help create a fuller picture of what matters to the person and what support may be needed next.

 

Assessment is only the starting point

Assessment creates insight, but insight has limited value unless it informs action. For CGA to make a difference, it must become part of the care planning cycle, not an assessment that sits separately from day-to-day decision-making.

The BGS primary care toolkit describes CGA as a holistic assessment that helps create a care plan focused on the needs and priorities of the older person and their carers, followed by ongoing support, review and reassessment. That means effective CGA should support:

• A clear care plan
• Agreed actions
• Named responsibilities
• Follow-up and review
• Communication with the person and their family
• Visibility across services

For older people with changing needs, continuity matters. Care planning needs to evolve as mobility, cognition, medication needs, social circumstances or support arrangements change over time.

Brandon Newman believes one of the most valuable aspects of shared CGA-informed care planning is reducing the need for older people and families to repeatedly retell their story across different services, while helping clinicians build a clearer chronological understanding of changing needs over time. 
The value of CGA therefore lies not only in identifying complexity, but in helping multidisciplinary teams coordinate a response around that complexity.

 

How shared CGA insight supports more coordinated care

Older people with frailty or complex needs are often known to multiple professionals and services at the same time. However, each team may only hold part of the overall picture. This creates operational challenges across integrated care systems and place-based teams. 

Repeated assessments, fragmented communication and inconsistent follow-up can all make coordinated care more difficult.

A shared CGA-informed care plan helps teams:

• Work from the same information
• Reduce repeated assessments
• Understand changes over time
• Identify earlier signs of deterioration
• Coordinate follow-up actions
• Align clinical, social and community support

This is where shared digital workflows become increasingly important. Within Graphnet’s CGA, shared care plans, follow-up actions and information sharing can be brought together across geriatricians, nurses, pharmacists, allied health professionals, social care and voluntary sector teams.

Rather than positioning assessment as a standalone document, the approach supports ongoing collaboration around the person’s needs, goals and risks. Brandon Newman emphasises the importance of understanding what is normal for the individual, particularly in urgent or unfamiliar care settings. Having access to a clearer picture of the person’s baseline, previous interventions and changing needs can help professionals make more informed and proportionate decisions when time and context are limited. 

This continuity helps professionals make more informed decisions in both planned and urgent care settings, particularly when individuals move between services or experience changes in condition.

 

Moving from reactive care to earlier intervention

One of the biggest opportunities within CGA is supporting earlier intervention before risks escalate into crises. When assessment insight is visible across services, teams are better placed to identify patterns and changes that may otherwise go unnoticed. This may include:

• Increasing falls risk
• Functional decline
• Cognitive deterioration
• Medication-related issues
• Poor nutrition
• Carer strain
• Repeated contacts with urgent care
• Changes in confidence, mobility or independence

Graphnet’s CGA approach supports clearer visibility of cognitive, physical and functional changes over time, helping teams recognise deterioration earlier and coordinate appropriate follow-up. This is particularly relevant for integrated care systems focused on prevention, reducing avoidable admissions and supporting more people to remain well at home.

Brandon Newman links this directly to the importance of delivering the right care in the right place at the right time, while also ensuring that the wishes and preferences of older people remain visible throughout decision-making.

He also highlights the risks associated with avoidable hospital admissions for frail older people, including deconditioning, delirium and loss of independence. Earlier identification of emerging risks can help teams intervene more proactively through community support, medication review, therapy input, falls prevention or wider social support.

The aim is not simply to respond faster when something goes wrong. It is to recognise when needs are changing before they reach crisis point.

 

What CGA means for families and carers

Families and unpaid carers are often the people holding fragmented care journeys together. They may coordinate appointments, manage medications, monitor changes at home and communicate with multiple professionals across different services. In many cases, they also carry the burden of repeating the same history and concerns across every new interaction.

A CGA-informed care plan helps provide:

• A clearer understanding of the person’s needs
• More consistent information from professionals
• Greater confidence in the care plan
• A clearer sense of next steps
• Better involvement in discussions where appropriate

Graphnet’s CGA approach supports families and carers through clearer information sharing, practical guidance and improved visibility of ongoing plans and actions.

Importantly, this isn’t only about improving operational efficiency, but also about reducing uncertainty and helping families feel more informed and supported as needs change over time.

For many carers, knowing that professionals are working from shared information and coordinated plans can provide reassurance that care decisions are being made in a more joined-up and person-centred way.

 

The role of digital care plans in making CGA usable at scale

CGA can be difficult to scale effectively when information is spread across separate systems, forms and professional notes. Digital care planning helps make assessment insight visible, usable and actionable across services. This supports:

• Shared access across multidisciplinary teams
• Structured workflows
• Visibility of clinical scores and relevant GP data
• Clear follow-up actions
• Ongoing review over time
• Reduced duplication
• Better continuity between care settings

Graphnet’s CGA solution supports a unified digital workflow that brings together assessment domains, clinical scoring, automatically surfaced GP data and shared care planning with follow-up actions. This allows professionals to contribute to and review a more complete picture of the person’s needs over time, rather than relying on disconnected records or isolated assessments.

The importance of usability has also been reflected by clinicians using the approach. 

Dr Joanna Seeley, Specialist Community Geriatrician, East Kent Urgent Care Services, Kent Community Hospitals Foundation Trust, said:  "As we all know, the focus is shifting towards neighbourhood health, which is a fantastic opportunity to support the move from hospital to community settings and from reactive to proactive care.

“I'm really excited that having the Comprehensive Geriatric Assessment (CGA) available within the Kent and Medway Care Record, supported by Graphnet, has enabled the system to give people a clear, consistent message: the proactive intervention we're asking you to deliver within neighbourhood teams is CGA.

“For many years we've talked about much vaguer concepts, but CGA has a strong evidence base. It means something to clinicians and provides real clarity and focus, supporting everyone to work together and pull in the same direction.”

For CGA to make a difference in practice, it needs to fit into the way multidisciplinary teams work. A digital workflow is only useful if it helps professionals access, update and act on information more easily, rather than adding another layer of administration.

Brandon Newman believes this visibility becomes particularly valuable in urgent or high-pressure environments where professionals may have limited prior knowledge of the individual. Access to a clearer chronological picture of the person’s history, baseline and previous interventions can support safer and more informed decision-making at the point of care. 

Digital care planning does not replace clinical judgement or relationships with older people and families. It supports them by making the right information easier to access, act on and review.

 

Building CGA into integrated care for older people

CGA should be viewed as part of a wider integrated care strategy for older people rather than a standalone clinical process. It supports broader NHS priorities around:

• Prevention and proactive care
• Personalised care
• Frailty management
• Dementia care
• Out-of-hospital support
• Population health management
• Better use of multidisciplinary teams

The BGS toolkit also highlights that CGA is particularly well suited to proactive care in community settings, while recognising the complexity of coordinating multidisciplinary working across services.

For integrated care systems, the goal is not simply better documentation. The goal is to support more coordinated, preventative care that reflects the needs, goals and circumstances of older people over time. That requires assessment insight to remain visible and actionable across the wider care journey.

 

Conclusion: Turning insight into better care

Comprehensive Geriatric Assessment brings together the information needed to understand an older person’s needs as a whole, but the real value of CGA comes when that insight informs a shared, living care plan that can be acted on across services, reviewed over time and used to support coordinated decision-making.

For health and care systems, this means moving beyond isolated assessments towards connected workflows that support proactive, multidisciplinary care for older people with complex needs.

Graphnet’s Comprehensive Geriatric Assessment solution helps health and care teams bring assessment insight, clinical scoring and shared care planning into one coordinated digital workflow. Learn more about Graphnet’s CGA solution.