From Sea to CGA: Delivering Geriatric Assessment to an Island Community

Abstract Background Rural and remote populations often experience poorer health outcomes due to geographic isolation, limited healthcare access, and economic disadvantage. As part of our Integrated Care Programme for Older Persons (ICPOP), we aimed to address the needs of complex older adults living on an offshore island within our catchment area. Methods The island, located 85 km from the nearest hospital (including road and sea travel), has a resident population of approximately 175–184. In partnership with the island’s Public Health Nurse (PHN), six older adults were identified for comprehensive geriatric assessment (CGA). A joint Advanced Nurse Practitioner (ANP) and consultant clinic was conducted, incorporating assessments at the PHN office and through home visits. Logistical challenges included coordinating ferry schedules and arranging local transport. Results Six residents (three men and three women) underwent CGA. The median age was 88.5 years, with Clinical Frailty Scores ranging from 3 to 6. The median Barthel Index was 18, and the median Lawton IADL score was 3. Key issues identified included a new diagnosis of dementia, polypharmacy, orthostatic hypotension, and previously untreated osteoporosis. Three individuals were referred had later intervention with the team physiotherapist. Conclusion Equitable access to care is vital for older adults in remote rural settings. ICPOP outreach clinics offer an effective means of delivering specialist assessment and timely intervention, reducing the risk of emergency or unscheduled hospital admissions. This model fosters local engagement and supports ageing in place. Future plans include the integration of virtual platforms such as Attend Anywhere to enhance continuity of care and support follow-up interventions.