Community Specialist Teams for Older Persons (CST-OP) at risk of, or living with frailty in Ireland: a prospective cohort study of a new model of integrated care for community dwelling older adults

Christina Hayes; Aoife Whiston; Christine Fitzgerald; Collette Devlin; Brian Condon; Molly Manning; Aoife Leahy; Katie Robinson; Rose Galvin

doi:10.1186/s12875-025-02895-x

Community Specialist Teams for Older Persons (CST-OP) at risk of, or living with frailty in Ireland: a prospective cohort study of a new model of integrated care for community dwelling older adults

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Abstract

Background: This study explored the clinical and process outcomes of older adults at risk of or living with frailty who received an interdisciplinary Comprehensive Geriatric Assessment (CGA) in the community. Methods: This prospective cohort study recruited older adults aged ≥ 75 who were screened for frailty and referred to one of three CST-OP hubs in the Mid-West of Ireland by their GP. Follow-up assessments were conducted via telephone by an independent assessor at 30- and 180-days. The primary outcome was functional status. Secondary outcomes included primary healthcare use, secondary healthcare use, nursing home admission, health-related quality of life (HRQoL), patient satisfaction and mortality. Results: A total of 303 participants (mean age = 83.2 years) were recruited. Incidence of 30- and 180-day functional decline was 26.4% and 33.7% respectively. The majority of older adults who availed of community-based CGA maintained functional independence up to 6-months post index visit. At 30-days, the mortality rate was 1.0%, Emergency Department (ED) presentation 6.9%, hospitalisation 6.6% and nursing home admission 4.0%. HRQoL significantly improved at 30- and 180-days. There was a significant improvement in HRQoL, F(2,542) = 13.8, p < 0.001, η² = 0.5. The presence of frailty was a significant predictor of adverse outcomes. Conclusion: Community-based CGA results in favorable health outcomes including HRQoL among community-dwelling older adults. Community-based CGA may also mitigate against potentially avoidable ED presentations and hospitalisations. Use of the Clinical Frailty Scale is recommended to predict the risk of functional decline, increased rates of mortality, NH admission, hospitalisation or ED presentation at 30- and 180-days among community-dwelling older adults. Trial registration: The study protocol was prospectively registered on Clinicaltrials.gov (NCT05527223). Registered January 09, 2022. https://clinicaltrials.gov.

Original language	English
Article number	193
Pages (from-to)	193
Journal	BMC Primary Care
Volume	26
Issue number	1
DOIs	https://doi.org/10.1186/s12875-025-02895-x
Publication status	Published - Dec 2025

Keywords

Aged
Aged, 80 and over
Female
Humans
Male
Aging in Place
Delivery of Health Care, Integrated/organization & administration
Frail Elderly
Frailty/therapy
Geriatric Assessment/methods
Hospitalization/statistics & numerical data
Independent Living
Ireland
Patient Care Team/organization & administration
Prospective Studies
Quality of Life

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Hayes, C., Whiston, A., Fitzgerald, C., Devlin, C., Condon, B., Manning, M., Leahy, A., Robinson, K., & Galvin, R. (2025). Community Specialist Teams for Older Persons (CST-OP) at risk of, or living with frailty in Ireland: a prospective cohort study of a new model of integrated care for community dwelling older adults. BMC Primary Care, 26(1), 193. Article 193. https://doi.org/10.1186/s12875-025-02895-x

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title = "Community Specialist Teams for Older Persons (CST-OP) at risk of, or living with frailty in Ireland: a prospective cohort study of a new model of integrated care for community dwelling older adults",

abstract = "Background: This study explored the clinical and process outcomes of older adults at risk of or living with frailty who received an interdisciplinary Comprehensive Geriatric Assessment (CGA) in the community. Methods: This prospective cohort study recruited older adults aged ≥ 75 who were screened for frailty and referred to one of three CST-OP hubs in the Mid-West of Ireland by their GP. Follow-up assessments were conducted via telephone by an independent assessor at 30- and 180-days. The primary outcome was functional status. Secondary outcomes included primary healthcare use, secondary healthcare use, nursing home admission, health-related quality of life (HRQoL), patient satisfaction and mortality. Results: A total of 303 participants (mean age = 83.2 years) were recruited. Incidence of 30- and 180-day functional decline was 26.4\% and 33.7\% respectively. The majority of older adults who availed of community-based CGA maintained functional independence up to 6-months post index visit. At 30-days, the mortality rate was 1.0\%, Emergency Department (ED) presentation 6.9\%, hospitalisation 6.6\% and nursing home admission 4.0\%. HRQoL significantly improved at 30- and 180-days. There was a significant improvement in HRQoL, F(2,542) = 13.8, p < 0.001, η2 = 0.5. The presence of frailty was a significant predictor of adverse outcomes. Conclusion: Community-based CGA results in favorable health outcomes including HRQoL among community-dwelling older adults. Community-based CGA may also mitigate against potentially avoidable ED presentations and hospitalisations. Use of the Clinical Frailty Scale is recommended to predict the risk of functional decline, increased rates of mortality, NH admission, hospitalisation or ED presentation at 30- and 180-days among community-dwelling older adults. Trial registration: The study protocol was prospectively registered on Clinicaltrials.gov (NCT05527223). Registered January 09, 2022. https://clinicaltrials.gov.",

keywords = "Aged, Aged, 80 and over, Female, Humans, Male, Aging in Place, Delivery of Health Care, Integrated/organization \& administration, Frail Elderly, Frailty/therapy, Geriatric Assessment/methods, Hospitalization/statistics \& numerical data, Independent Living, Ireland, Patient Care Team/organization \& administration, Prospective Studies, Quality of Life",

author = "Christina Hayes and Aoife Whiston and Christine Fitzgerald and Collette Devlin and Brian Condon and Molly Manning and Aoife Leahy and Katie Robinson and Rose Galvin",

note = "{\textcopyright} 2025. The Author(s).",

year = "2025",

month = dec,

doi = "10.1186/s12875-025-02895-x",

language = "English",

volume = "26",

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Hayes, C , Whiston, A, Fitzgerald, C, Devlin, C, Condon, B, Manning, M , Leahy, A , Robinson, K & Galvin, R 2025, 'Community Specialist Teams for Older Persons (CST-OP) at risk of, or living with frailty in Ireland: a prospective cohort study of a new model of integrated care for community dwelling older adults', BMC Primary Care, vol. 26, no. 1, 193, pp. 193. https://doi.org/10.1186/s12875-025-02895-x

Community Specialist Teams for Older Persons (CST-OP) at risk of, or living with frailty in Ireland: a prospective cohort study of a new model of integrated care for community dwelling older adults. / Hayes, Christina ; Whiston, Aoife; Fitzgerald, Christine et al.
In: BMC Primary Care, Vol. 26, No. 1, 193, 12.2025, p. 193.

Research output: Contribution to journal › Article › peer-review

TY - JOUR

T1 - Community Specialist Teams for Older Persons (CST-OP) at risk of, or living with frailty in Ireland

T2 - a prospective cohort study of a new model of integrated care for community dwelling older adults

AU - Hayes, Christina

AU - Whiston, Aoife

AU - Fitzgerald, Christine

AU - Devlin, Collette

AU - Condon, Brian

AU - Manning, Molly

AU - Leahy, Aoife

AU - Robinson, Katie

AU - Galvin, Rose

PY - 2025/12

Y1 - 2025/12

N2 - Background: This study explored the clinical and process outcomes of older adults at risk of or living with frailty who received an interdisciplinary Comprehensive Geriatric Assessment (CGA) in the community. Methods: This prospective cohort study recruited older adults aged ≥ 75 who were screened for frailty and referred to one of three CST-OP hubs in the Mid-West of Ireland by their GP. Follow-up assessments were conducted via telephone by an independent assessor at 30- and 180-days. The primary outcome was functional status. Secondary outcomes included primary healthcare use, secondary healthcare use, nursing home admission, health-related quality of life (HRQoL), patient satisfaction and mortality. Results: A total of 303 participants (mean age = 83.2 years) were recruited. Incidence of 30- and 180-day functional decline was 26.4% and 33.7% respectively. The majority of older adults who availed of community-based CGA maintained functional independence up to 6-months post index visit. At 30-days, the mortality rate was 1.0%, Emergency Department (ED) presentation 6.9%, hospitalisation 6.6% and nursing home admission 4.0%. HRQoL significantly improved at 30- and 180-days. There was a significant improvement in HRQoL, F(2,542) = 13.8, p < 0.001, η2 = 0.5. The presence of frailty was a significant predictor of adverse outcomes. Conclusion: Community-based CGA results in favorable health outcomes including HRQoL among community-dwelling older adults. Community-based CGA may also mitigate against potentially avoidable ED presentations and hospitalisations. Use of the Clinical Frailty Scale is recommended to predict the risk of functional decline, increased rates of mortality, NH admission, hospitalisation or ED presentation at 30- and 180-days among community-dwelling older adults. Trial registration: The study protocol was prospectively registered on Clinicaltrials.gov (NCT05527223). Registered January 09, 2022. https://clinicaltrials.gov.

AB - Background: This study explored the clinical and process outcomes of older adults at risk of or living with frailty who received an interdisciplinary Comprehensive Geriatric Assessment (CGA) in the community. Methods: This prospective cohort study recruited older adults aged ≥ 75 who were screened for frailty and referred to one of three CST-OP hubs in the Mid-West of Ireland by their GP. Follow-up assessments were conducted via telephone by an independent assessor at 30- and 180-days. The primary outcome was functional status. Secondary outcomes included primary healthcare use, secondary healthcare use, nursing home admission, health-related quality of life (HRQoL), patient satisfaction and mortality. Results: A total of 303 participants (mean age = 83.2 years) were recruited. Incidence of 30- and 180-day functional decline was 26.4% and 33.7% respectively. The majority of older adults who availed of community-based CGA maintained functional independence up to 6-months post index visit. At 30-days, the mortality rate was 1.0%, Emergency Department (ED) presentation 6.9%, hospitalisation 6.6% and nursing home admission 4.0%. HRQoL significantly improved at 30- and 180-days. There was a significant improvement in HRQoL, F(2,542) = 13.8, p < 0.001, η2 = 0.5. The presence of frailty was a significant predictor of adverse outcomes. Conclusion: Community-based CGA results in favorable health outcomes including HRQoL among community-dwelling older adults. Community-based CGA may also mitigate against potentially avoidable ED presentations and hospitalisations. Use of the Clinical Frailty Scale is recommended to predict the risk of functional decline, increased rates of mortality, NH admission, hospitalisation or ED presentation at 30- and 180-days among community-dwelling older adults. Trial registration: The study protocol was prospectively registered on Clinicaltrials.gov (NCT05527223). Registered January 09, 2022. https://clinicaltrials.gov.

KW - Aged

KW - Aged, 80 and over

KW - Female

KW - Humans

KW - Male

KW - Aging in Place

KW - Delivery of Health Care, Integrated/organization & administration

KW - Frail Elderly

KW - Frailty/therapy

KW - Geriatric Assessment/methods

KW - Hospitalization/statistics & numerical data

KW - Independent Living

KW - Ireland

KW - Patient Care Team/organization & administration

KW - Prospective Studies

KW - Quality of Life

U2 - 10.1186/s12875-025-02895-x

DO - 10.1186/s12875-025-02895-x

M3 - Article

C2 - 40474059

SN - 2731-4553

VL - 26

SP - 193

JO - BMC Primary Care

JF - BMC Primary Care

IS - 1

M1 - 193

ER -

Community Specialist Teams for Older Persons (CST-OP) at risk of, or living with frailty in Ireland: a prospective cohort study of a new model of integrated care for community dwelling older adults

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