Pro-active care for the older people at risk for functional decline: Screening for vulnerability and effectiveness of a subsequent guided care plan in primary care

The number of older people with a combination of somatic, functional, mental or
social problems is rising. The problems these older people are facing are not
always known to care-providers. The general practitioner (GP) may sometimes
suspect the presence of some of these problems, but usually only acts on
demand. For vulnerable elders a screening/monitoring and proactive way of
working is important, although this is not yet common in primary care.

The aim of this project is to introduce a simple structural monitoring system
to detect the deterioration in somatic, functional, mental or social health of
individuals aged 75 years and over. Subsequently, a care plan will be made for
those older people with a combination of somatic, functional, mental and social
problems.

Seventy general practices will be recruited from the region around Leiden.
These 70 practices will be randomized 1 to 1 at practice level after all
patients of 75 years have been selected form the Electronic Patient record
(EPR).
The GPs and practice staff of the intervention group will then be trained in
designing, executing and adjusting the care plan. In all 70 practices a short
questionnaire with questions about somatic, functional, mental and social
health is sent to all people of 75 years and older. The results of this
questionnaire will be fed back to the GP's of the intervention group who will
formulate a care plan, together with the particular older person, his/her
caregiver and deliberated with other caretakers for older people with problems
on 3 or 4 domains. For patients with problems in 1 or 2 domains the GP will
initiate individual or programmatic interventions.

All older people with problems on 3 or 4 domains and a representative sample of
the participants with problems on 0, 1 or 2 domains will be visited by a
research nurse to administer a number of additional questionnaires, necessary
for baseline measurements. After 12 and after 24 months those older people
will be visited again. The results of these additional questionnaires will not
be fed back to the GP.

In the intervention group (35 practices), results of the screening
questionnaire are sent back to the GP and are registered in the Electronic
Patient Records (EPR) of the GP. The GP, in cooperation with practice staff
(e.g. practice nurse, GP*s assistant), makes a care plan for all older people
with problems in three or four of the four domains in the questionnaire after
an exploratory interview with the patient and his/her caretakers. Depending on
the seriousness of the problems and the kind of problems, the care plan will
incorporate indicated diagnostic strategies, indicated interventions,
medication review, referral to home care, contact with social work, treatment
by paramedics or bringing together all caregivers involved in the care for the
patient. GP and practice staff will be trained to implement this monitoring and
pro-active way of working. The opinion and capabilities of the older person
and his/her family and caretakers are included in this process.
For patients with problems in 1 or 2 domains the GP will initiate individual or
programmatic interventions

Burden: It will take the participants a maximum of 15 minutes to fill in the
screening questionnaire. All older people with problems in 3 or 4 of 4 domains
and a representative sample of older people with problems in 0, 1 or 2 domains
will be visited at home to administer additional questionnaires. This visit
will take approximately one and a half hour. During this visit the research
nurse administers questionnaires necessary for baseline of outcome
measurement. In the intervention group, the GP may ask the older patient to
pay him/her a visit at the practice or the GP visits the older patient at home
to discuss a care plan tailored to the individual patient. In both intervention
and control group, the screening questionnaire and outcome measurements will be
repeated after 12 and after 24 months. After 6 months all participants receive
the screening questionnaire and a questionnaire for the economic evaluation.

Risk: No additional risks are involved in this project compared to standard
care. The interventions that will be used in the care plans or as programmatic
intervention are commonly used or prescribed in General Practice. All standard
care is according to current treatment guidelines.

Benefits: Early detection of vulnerability and offering integrated care is
likely to be more effective and beneficial to prevent deterioration in
functional abilities.