The aim of the project is to evaluate the best method of supported care in general practice that leads to greater self-sufficiency, higher retention of functions and thus improved quality of life, less use of care facilities and a lower burden of…
ID
Source
Brief title
Condition
- Other condition
Synonym
Health condition
chronische ziekten
Research involving
Sponsors and support
Intervention
Outcome measures
Primary outcome
The primary outcome parameter is change in daily functioning. Daily functioning
(ADL) is measured with the Katz 15 questionnaire which is embedded in the
Minimal Data Set questionnaire.
Secondary outcome
Secondary outcome parameters are:
1. Quality of life (RAND-36, EQ5D, both embedded in the Minimal Data Set)
2. Care use (number of referrals, admittances, prescriptions, diagnoses and
visits) expressed in:
a) number of *elective* interventions in secondary care (planned
admittances);
b) number of *emergency* admittances in secondary care, nursing homes and
older people homes homes;
c) number of contacts with the general practitioner*s surgeries, outside the
regular hours;
d) number of contacts with the healthcare assistant, the general
practitioner, the general practice assistant and GNPC;
e) medication use, dysfunctional and functional polypharmacy;
f) consultation with other primary carers (AMW (General Social Work),
physiotherapy, homecare);
3. Mortality
4. Cost-effectiveness analysis (CEA)
For the CEA, the ratio of differences in the main outcome measure - (I)ADL -
between the three groups and differences in costs will be analyzed.
5. Patient satisfaction
Patient satisfaction will be measured in the Minimal Data Set.
6. Comparison of frailty index courses between groups, with particular
attention to the proportion of patients with polypharmacy, multimorbidity and a
care gap of > 3 years. Secondly, focus on the correlation of frailty index
scores with daily functioning and quality of life as reported in the Minimal
Data Set.
7. Time spent on informal caring and burden of this care for the informal
carer; health status and quality of life of informal carer.
The secundary outcome parameters are partly measured with the extraction of
routine care data by UPRIM, and partly with data acquired in the Minimal Data
Set questionnaires (the MDS for the participants as well as for the informal
carers).
Background summary
With the increase of older people in society it can also be expected that the
number of older people with increased frailty will rise. The precise definition
of the term *frailty* is still being discussed in the international arena. This
project uses the following definition: *a loss of resources in various
functional domains that leads to decreased reserve capacity to deal with
stress.* (source: National Elderly Care Programme (Nationaal Programma
Ouderenzorg) 2008-2011, Steverink N, Slaets J.P.J, Schuurmans H, van Lis M,
Gerontologist 2001).
Older people with multi-morbidity interviewed in the Utrecht region experience
problems with a lack of *overview* by their primary care givers and a lack of
care coordination. This was discovered during research carried out last year by
the Utrecht Patients* Support Group (CliëntenBelang Utrecht). 'What I need is
someone who knows what*s going on and can see things from my side.* This
heartfelt cry was made by an older person with multimorbidity in the Utrecht
region. Older people in the region wish to be kept informed and need someone
who can help them to make well-considered decisions with regard to their
health. Health care professionals do not coordinate care sufficiently, nor do
they keep each other adequately informed. The Central Utrecht Elderly Care
Project (Om U) aims to provide the answer to older peoples* need for more
coordination of care and integrated care.
Study objective
The aim of the project is to evaluate the best method of supported care in
general practice that leads to greater self-sufficiency, higher retention of
functions and thus improved quality of life, less use of care facilities and a
lower burden of care for older people. This will be brought about by adequately
monitored adaptations to the existing care structure.
Study design
A cluster randomized, controlled, single blind intervention study in the
general practice. A three-armed study design is used to compare the effects of
two interventions with the usual care group during a 12 months follow-up
period.
Intervention
1. Periodic (quarterly) Risk Identification of frailty and Monitoring of care
to older people (UPRIM) in electronic medical records of the general practice.
2. UPRIM plus the introduction of a specially trained Geriatric Nurse Primary
Care (GNPC), who maintains contact with the patient and their caregivers,
develops and monitors an individual care plan and coordinates the care provided
by all involved parties. Patients will also be visited by the GNPC at their
homes.
Study burden and risks
Patients will be asked to fill in a questionnaire three times a year. Filling
in these questionnaires will take about 20-30 minutes each time. Besides that,
patients in the intervention group of UPRIM and the GNPC will have one or more
home visits of the GNPC, depending on the level of care required.
Heidelberglaan 100, Utrecht
3508 GA Utrecht
NL
Heidelberglaan 100, Utrecht
3508 GA Utrecht
NL
Listed location countries
Age
Inclusion criteria
Potentially frail older people; patients of 60 years and older in general practice setting with one or more of the following three criteria:
- multimorbidity (defined as a frailty index score of 0.20 or higher, for eleborate details see chapter 5 of the protocol), AND/OR
- polypharmacy (5 or more different drugs in actual chronic use), AND/OR
- care gap (more than three years no contact with the general practice, except for the yearly influenzae vaccination)
Exclusion criteria
- terminally ill patients
- patients living in an elderly care home or nursing home
- patients on a waiting list for an elderly care home or nursing home
Design
Recruitment
Followed up by the following (possibly more current) registration
No registrations found.
Other (possibly less up-to-date) registrations in this register
No registrations found.
In other registers
| Register | ID |
|---|---|
| CCMO | NL30071.041.10 |