See what informs our approach to care

WHO guidance connects initial and in-depth assessment with a personalised plan, implementation and monitoring in primary and community care.

Relevance and limits: Informs starting with the person’s needs, agreeing goals and reviewing care. This is clinical guidance, not a trial of Clinics GRP’s service or a guarantee of benefit.

Across 129 studies involving 74,946 participants, individualised care planning with tailored actions, medication review and regular follow-up was among the most promising approaches for sustaining independence. Effects varied: most comparisons had low or very-low certainty, and the living-at-home estimate for this combination included no difference.

Relevance and limits: Informs linking assessment to specific actions and scheduled review, with medication review by appropriately qualified professionals where indicated. More services are not automatically better; some combinations reduced independence. This supports personalised decisions, not a promise that this pathway prevents residential care.

A review of 22 trials of home-based comprehensive geriatric assessment found a small improvement in function at 6–24 months (standardised mean difference 0.17; 95% confidence interval 0.09–0.25; low-certainty evidence). There was little or no difference in nursing-home admission or emergency-department presentation.

Relevance and limits: Informs assessment in the person’s everyday environment, tailored planning and coordinated follow-up. Comprehensive geriatric assessment involves specialist expertise and a broader multidisciplinary model; an individual Clinics GRP discipline assessment is not equivalent to that intervention.

The review found high-certainty evidence that exercise reduces falls in older adults living in the community. Balance and functional exercise were key components; evidence for several other exercise types and non-fall outcomes was less certain.

Relevance and limits: Supports appropriately prescribed physiotherapy and exercise after assessment. It does not show that this pathway prevents falls for every person, or that any exercise package is suitable for everyone.

High-certainty evidence supports home fall-hazard reduction for older people selected for higher falls risk. In that group, the rate of falls was reduced by 38% (rate ratio 0.62; 95% confidence interval 0.56–0.70). There was no evidence of benefit in people not selected for falls risk.

Relevance and limits: Informs asking about falls and daily function during intake, assessing relevant home risks and referring for appropriate environmental assessment or modifications. It does not establish that a general home visit or advice alone has the same effect, or that modifications are automatically funded.

WHO’s safety framework identifies medication processes, high-risk situations, polypharmacy and transitions of care as priorities for reducing avoidable harm.

Relevance and limits: Informs clear medicines information, communication, monitoring and escalation within nursing scope. It does not expand prescribing authority or establish the effectiveness of this service.

This review found possible short-term benefits for some low-back-pain presentations, with low or very-low certainty evidence.

Relevance and limits: Supports cautious, assessed use rather than general recovery claims. These findings cannot be generalised to all older people or all conditions, and they do not establish Support at Home funding eligibility.

Across 49 trials involving 25,566 adults with complex care needs, pooled readmission risk was lower with multidisciplinary transitional care (RR 0.88; 95% CI 0.80–0.96). Certainty was low because results differed between studies and publication bias was possible.

Relevance and limits: Supports coordinated transition as a design principle; it does not predict an individual’s outcome or prove this service reduces readmissions.

For medical admissions, personalised discharge planning slightly reduced hospital stay and readmission over about three months (RR 0.89; 95% CI 0.81–0.97; moderate-certainty evidence).

Relevance and limits: Informs preparation and transfer of care. A single referral is an operational choice, not an independently proven intervention.

This review identified person-centred, tailored and continuous care, a small team, follow-up and carer involvement among components of transitional care models.

Relevance and limits: Informs the proposed clinical lead and shared plan; the effect of each individual component cannot be isolated.

A review of 22 trials in at-risk older adults found a small improvement in function with home-based comprehensive geriatric assessment at 6–24 months (SMD 0.17; 95% CI 0.09–0.25).

Relevance and limits: Supports looking beyond one discipline. Clinics GRP’s early home review is not a formal Comprehensive Geriatric Assessment and does not reproduce the full intervention studied.

Trials integrating informal carers into discharge planning reported fewer readmissions at 90 and 180 days than usual care.

Relevance and limits: Informs checking understanding of the plan and involving the person’s chosen support people, with consent. These findings are not service-level outcome claims.

Ten trials of home exercise after hospitalisation found improvements in some measures of daily activity, mobility and quality of life, depending on the comparison.

Relevance and limits: Supports considering individually prescribed rehabilitation; it does not establish that every person benefits from the same exercise package.

In 740 older people with frailty, the extended home exercise programme did not improve the primary physical quality-of-life outcome at 12 months and was not cost-effective.

Relevance and limits: This cautions against routine extended exercise for everyone after discharge. It does not validate Clinics GRP’s alternative model; assessment, reassessment and service evaluation remain necessary.