Objective: to ascertain the value of employing a specialist clinician's contribution to the assessment of older people prior to care home entry.
Design: randomised controlled trial.
Method: 256 older people at risk of care home entry were randomly allocated to either a control group, who received the usual care management assessment, or to an experimental group who, in addition, received a clinical assessment by a geriatrician or old age psychiatrist. The value of the additional assessment was evaluated by an analysis of clinical recommendations, questionnaires eliciting the views of stakeholders and research interviews with older people and their carers at initial assessment and 6 months. Data on service use and costs over 6 months and on destination at 6 and 12 months were also collected.
Results: the clinical assessment uncovered covert morbidity previously unknown to care managers particularly in respect of cognitive impairment and was adjudged acceptable to the different stakeholders involved. Those receiving the clinical assessment experienced less deterioration in their physical functioning, had less contact with nursing homes and emergency services and their carers experienced reduced levels of distress. Overall, the costs of care for those receiving the assessment were no greater with NHS costs actually lower.
Conclusions: the potential benefits in involving specialist clinicians in the assessment process include identifying previously undiagnosed conditions and enhancing care managers' decision making. Such an assessment could be provided at a modest marginal cost. The approach is fully compatible with proposals for the role of the community geriatrician and commensurate with current good clinical practice in old age psychiatry.