Table 3 Factors integral to understanding Geriatric Services Hub implementation
S/N | Factors | Brief description |
|---|---|---|
1 | Patient screening | Identifying frail older persons in the community for the GSH |
2 | Multi-disciplinary assessment | Conducting frailty assessment using a CGA, followed by multi-disciplinary team meetings involving geriatricians, geriatric nurses and allied healthcare professionals in the discussion of care. |
3 | Comprehensive service package | Developing and implementing individualised care plans, including referrals to frailty-related services to meet identified needs. |
4 | Network relationships | Partnerships and working arrangements between GSH site and partner organisations, such as primary care providers, community health and social service providers, including information sharing between them. |
5 | Care management | Planning care and coordinating care across time, place and discipline. |
6 | Continuity of coverage and care | Provider’s ability to help patients access frailty-related services across different settings and providers. |
7 | Seamless/Ease of transition | Patient’s ability to access frailty-related services and navigate between different settings and providers. |
8 | Teamwork | Roles and responsibilities of the GSH core team members; ongoing communication and collaboration among the multi-disciplinary group of providers. |
9 | Patient-centred care | The extent to which clinicians and patients work together to make decisions and select tests, treatments and care plans based on evidence that balances risks and intended outcomes with patient preferences and values. |
10 | Strategic planning | Stakeholder involvement in joint planning and community needs assessment |
11 | Funding mechanism | Structure of funding for health and social care. |
12 | System outcomes | Overall responsibility for the intended outcomes. |