Central Utrecht Elderly Care Project 'Om U': “Somebody who knows what’s going on and can see things from my side.”

In the Central Utrecht Elderly Care Project, the transition will be made from reactive towards proactive care for potentially frail older people in general practices. The hypothesis is that more proactive care 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 and their informal carers.

In general practices, proactive care for potentially frail older people with the use of Utrecht Periodic Risk Identification and Monitoring (UPRIM) and the use of a Geriatric Nurse Primary Care (GNPC) will result in better daily functioning in comparison to potentially frail older people who receive care as usual.

Both primary and secondary parameters are recorded in all three groups (groups A, B and C) on three different measurement moments:

1. After randomization at baseline (TO);

2. After six months (T1);

3. After 12 months (T2).



For the primary and secondary outcome measures, MDS data as well as UPRIM data will be used.

The MDS is obligatory used nationwide in all projects which are part of the National Program of Elderly Care. It includes questions about general well-being, psychological and social functioning, cognitive functioning, multi-morbidity and ADL functioning, as well as questions pertaining to demographic information.

1. Group A: Utrecht Periodic Risc Identification and Monitoring (UPRIM).

UPRIM is a method adapted for elderly care also known in the literature as panel management. It entails preventive identification of potentially frail older people on the basis of automatic quarterly screening for relevant risk factors in the Electronic Medical Records of the GP. Using ICPC / ATC codes, UPRIM will screen for three core components: multimorbidity, polyfarmacy and care gap, scored positive as defined in the inclusion criteria section.

The result is a UPRIM report for each general practice of older people who can be classified as ‘potentially frail’. With this report, the GP has the possibility to carry out (preventive) interventions and coordination of care. the interventions required in follow-up of the UPRIM report are not described in a protocol, but are left up to the GP, who follows the usual protocols, standards and guidelines for best practices in primary care.



2. Group B: UPRIM & Geriatric Nurse Primary Care (GNPC).

In the second intervention group, following UPRIM, a specially trained GNPC will provided a structured care program for each of the domains of frailty . The GNPC will send 3 questionnaires: the Groningen Frailty Index (GFI), the Intermed Self Assessment and the Groningen Wellbeing Questionnaire. Patients will return the questionnaires to the General Practice. The GNPC will discuss the outcome with the GP and makes an appointment with the patient to visit the patient at home. During this home visit the GNPC takes some geriatric assessments and will develop an tailor made care plan. Assessments are bases on ten common health problems; functional decline, falling, mood and loneliness, urinary incontinence, malnutrition, visual impairment & hearing loss, cognition, polypharmacy, caregiver burden, and wellbeing. The GNPC will discuss this first drafts with the GP. The GNPC will monitor ands register progress and type of interventions after each visit.



3. Group C: Control group.

Patients in this group will receive care as usual.