An evaluation of an integrated primary care approach to improve well-being among frail community-dwelling older people

Introduction: A major challenge in primary health care is the substantial increase of the proportion of frail older persons with long-term conditions and multiple complex needs. The traditional primary care system in the Netherlands is fragmented and reactive. Consequently, current primary health care is not able to cope effectively with the increasing demands for health and social care, and to improve well-being among frail community-living older people. This calls for a fundamental transformation of current models of primary care by adopting integrated care. Therefore, the aim is to improve quality of primary care and well-being of frail community-living older people by implementing and evaluating an innovative integrated care approach, which is called Finding and Follow-up of the Frail (FFF).

Methods: The integrated primary care approach FFF

The overall aim of the FFF approach is to redesign primary care for frail community-dwelling older people in order to enhance patient outcomes and quality of care. The core elements of the FFF approach are (1) the proactive case finding of frail older people in the community by means of assessing frailty in the physical, psychological and social domain, (2) establishing an integrated primary care system including case management and individualized care plans, (3) realizing effective coordination between health and social sectors and forming multidisciplinary care teams, and (4) engaging older people towards self-care and self-management, and empowering them to coproduce care. The FFF approach has been implemented in several GP practices in the western part of the Province of Brabant in the Netherlands.

Study design: The ongoing (cost)effectiveness study has a matched quasi-experimental design with a pretest and posttest (12 month follow-up) and is conducted between September 2014 and June 2016. A combination of quantitative and qualitative research methods are employed to evaluate effects, processes and costs of the FFF approach. In total, 356 frail older persons (75 years and older) of 11 GP practices that implemented the FFF approach are compared with 235 frail older people of 4 GP practices providing care as usual. The primary outcome measure is well-being (Social Production Function Instrument for the Level of well-being [SPF-IL]). Several secondary outcomes are measured, like self-management abilities (Self-Management Ability Scale Short version [SMAS-S]). In addition, data are collected from health care professionals on several outcome measures, for example quality of integrated care (Assessment of Chronic Illness Care Short version [ACIC-S]). The ACIC-S is based on the six areas of system redesign proposed by the Chronic Care Model (CCM). Other measures include functioning of multidisciplinary teams and care coordination. Baseline measures will be compared with the outcomes on the 12 month follow-up by means of multilevel analyses and the (cost)effectiveness of the FFF approach will be determined.

Results: At baseline, frail older people (N=589) had a mean age of 83.7 years (SD = 5.2) and 68.4% were women. The mean well-being score within the study population was 2.63 (SD = 0.49, range 1-4 with higher scores indicating greater well-being). With respect to self-management abilities, a mean score of 3.67 (SD = 0.88, range 1-6 with higher scores indicating higher self-management abilities) was reported. Health care professionals involved in the FFF approach (N=52) were (geriatric) nurses or practice nurses (25%), general practitioners (21.2%), physiotherapists (7.7%), elderly care physicians (5.8%) or other professionals (e.g. case managers). The mean ACIC-S score was 6.36 (SD = 1.31, range 0-11), indicating advanced integrated care delivery. Scores on all six CCM dimensions can be improved in order to optimize quality of integrated care for frail community-living older people. Both outcome measures of frail adults and health care professionals will be presented.

Preliminary results of the (cost)effectiveness of the FFF approach will be presented at the International Conference on Integrated Care 2016. The effects of the FFF approach compared with care as usual on well-being and quality of care will be discussed. An extensive description of the FFF approach and its barriers and facilitators will be provided. Furthermore, we will discuss the expected benefits, sustainability and transferability.

Discussion and conclusion: The implementation and evaluation of the FFF approach is an important step towards a more integrated care model for frail community-dwelling adults in the Netherlands. This ongoing evaluation study will reveal preliminary insights into the rationale and effectiveness of an integrated primary care approach. The process of integrating care and social services across the continuum of primary care and across professional boundaries is reflected upon. An implication for future research is to extend the follow-up period in order to determine the long-term effects of the integrated care approach.