The frail elderly person at the centre of cohesive care.

Objective:

The primary aim is that the geriatric care model improves quality of life of the older frail participating persons as compared to care as usual.

The secondairy aims are that the geriatric care model leads to:

1. More maintance of functional ability, a decrease in unmet care needs, a decrease in acute hospital admissions among the older frail participating persons as compared to care as usual;

2. Among the informal caregivers of participating older frail persons: a reduction in perceived care load and a better quality of life as compared to care as usual;

3. High quality care and efficient care.


STUDY DESIGN

A stepped wedge cluster randomised trial. Baseline measures will be taken directly after inclusion of the elderly
person. Follow-up measures are taken 6, 12, 18 and 24 months after baseline. All participating general practices will eventually work according to the GCM, but the starting moments are phased and determined at random. In total, 40 general practices will be randomised in 4 tranches of 10 practices with starting dates that are spaced 6
months apart. During the waiting period, standard care is provided. Six monthly follow up measurements (process and outcomes) are scheduled during two years.


STUDY POPULATION

1. 1200 frail elderly persons 65 years of age or older who live idependently. Frail persons will be identified by screening (medical files) and case finding by health care professionals of Ouderennet VUmc & partners;

2. If present, the (approximately 850) primary informal carer of persons in the frail persons will be approached for participation in the project.


OUTCOMES

A. EVALUATION OF EFFECT

(1) Elderly persons: (a) Quality of life (SF-12); (b) Self-sufficiency and functioning (Katz ADL), (c) care needs (CANE), (d) acute hospital admissions.
(2) Informal carers: (a) Perceived care load (MDS-item), (b) quality of life (SF12).
(3) Professionals and organisation: Quality of care (ACOVE and RAI indicators).

B. EVALUATION OF PROCESS

Degree to which all elements of the Geriatric Care Model are applied.

Identification of facilitating and impeding factors in the implementation on micro (patient and care
provider), meso (care organisation) and macro level (financing, legal). The focus groups identify such
factors as well.

C. ECONOMIC EVALUATION

(Cost of) care usage (MDS items complemented by care registrations).

Vulnerable 65+ years persons who participate the Geriatric Care Model will experience a better Quality of Life compared to elderly persons receiving care as usual.

Baseline measures will be taken directly after inclusion of the elderly person. Follow-up measures are taken 6, 12, 18 and 24 months after baseline.

GERIATRIC CARE MODEL

The Geriatric Care Model will have a staged implementation. The Geriatric Care Model comprises the following steps:

1. Geriatric assessment of health risks and care needs by nurses; devising a care plan with state-of-the-art interventions, taking into account the wishes of the elderly; half-yearly re-assessment of the health risks and care needs by the nurses and, if necessary, adjustment of the care plan;.

2. Consulting a multi-disciplinary geriatric team on complex patients;

The care process will be changed:

3. Nurses head for alignment and encourage patient empowerment through illness/risk education and through discussion of the care plan with family person;

4. Care processes are controlled, like the chronic care model. A geriatric team heads for quality of care and implementation of the geriatric care model in Amsterdam-Zuid&Amstelveen and Westfriesland. Approximately 40 general practices, home care organisations, residential and nursing homes, social service centres, mental health institutions in the participating regions will actively take part in recruitment and the provision of care and support.



All participating general practices will eventually work according to the GCM, but the starting moments are phased and determined at random. In total, 40 general practices will be randomised in 4 tranches of 10 practices with starting dates that are spaced 6
months apart. During the waiting period, standard care is provided.