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Article History

Received: 13 December 2022

Accepted: 19 February 2024

First Online: 19 March 2024

Declarations

:

: Ethical approval was not needed as this was a quality improvement study that evaluated the direct care that patients received from teams that were directly involved in their care. The need for ethics approval and consent to participate was therefore waived under General Data Protection Regulations articles 6 and 9. As this was a quality improvement activity evaluating direct patient care, data was evaluated with a linked dataset and an information sharing agreement between the local hospital and GP surgery. General Data Protection Regulations articles 6 and 9 offer a lawful basis for this. No administrative permissions were required to access the raw data as this was a service evaluation of direct care and only direct care teams who were directly involved in patient care were able to access the data. A Data Protection Impact Assessment was completed to mitigate against data-sharing risks. All patient identifiable details were removed apart from NHS number, frailty diagnosis, age, dementia diagnosis, i-CGA completion, ACP preferences, date, and place of death. This register was shared with the Community Services Business Intelligence unit, which extracted hospitalisation metrics and location of death. All methods in this study were carried out in accordance with relevant guidelines and regulations for quality improvement studies.

: Not applicable.

: The IT software that enabled the case-finding tool to be developed was originally designed in on primary care IT in Pathfields Medical Group. In January 2020 many practices in the Plymouth locality expressed a strong desire to use the Pathfields Tool so that they could improve the care of older people. To mitigate against any liability for the Pathfields partnership and to allow sharing of this software with other practices, this tool was relocated to a community interest company called Sentinel. The long-term ambition is to develop a private company that develops IT templates for primary care. Ultimately, this IT software will be housed in this private company but will remain free and available for all healthcare professionals to use, indefinitely. We developed the IT-assisted Comprehensive Geriatric Assessment (i-CGA), assisted by Target Health Solutions (THS, a company that enhances primary care IT). This was incorporated on our IT system, SystmOne, to offer proactive CGAs to residents. DA and JB are directors in THS.