A nurse-led interdisciplinary primary care approach to prevent disability among community-dwelling frail older people: A large-scale process evaluation

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Abstract

Background

The complex healthcare needs of frail older people and their increased risk of disability require an integrated and proactive approach. In the Netherlands, an interdisciplinary primary care approach has recently been developed, involving individualized assessment and interventions (tailor-made care), case management and long-term follow-up. The practice nurse as part of a general practice is case manager and plans, organizes and monitors the care process and facilitates cooperation between professionals. The approach has shown positive indications regarding its feasibility in a small pilot, but its implementation on a large scale had not hitherto been investigated.

Objectives

To examine the extent to which the interdisciplinary care approach is implemented as planned and to gain insight into healthcare professionals’ and frail older people's experiences regarding the benefits, burden, stimulating factors and barriers.

Design

A process evaluation was conducted using a mixed methods design.

Settings

Six GP practices in the south of the Netherlands.

Participants

Practice nurses (n = 7), GPs (n = 12), occupational therapists (n = 6) and physical therapists (n = 20) participated in the process evaluation. Furthermore, 194 community-dwelling frail older people (≥70 years) were included using the Groningen Frailty Indicator. People who were terminally ill, were confined to bed, had severe cognitive or psychological impairments or were unable to communicate in Dutch were excluded.

Methods

Quantitative data (logbooks and evaluation forms) were collected from all the participating frail older people and 13 semi-structured interviews with a selection of them were conducted. In addition, data from healthcare professionals were collected through 12 semi-structured interviews and four focus group discussions.

Results

Although some parts of the protocol were insufficiently executed, healthcare professionals and frail older people were satisfied with the care approach, as it provided a useful structure for the delivery of geriatric primary care and increased the attention to preventive treatment. Frail older people felt acknowledged by healthcare professionals and experienced support in handling their problems and fulfilling their wishes.

Conclusions

The findings of the study revealed several positive aspects of the interdisciplinary primary care approach. Given its complexity, the implementation of the nurse-led interdisciplinary care approach is challenging and some parts of the protocol need special attention.

Section snippets

Background

Frail older people often suffer from a combination of acute and chronic diseases (multimorbidity) and functional impairments leading towards disability and dependency on long-term care (Fried et al., 2004). In general, older people prefer to stay at home for as long as possible (Henderson and Caplan, 2008). However, community-based care is challenging, due to the complex healthcare needs of frail older people, which have to be addressed by various healthcare professionals (Markle-Reid and

Study design

Between February 2010 and December 2011 the PoC approach was evaluated in a large-scale process evaluation among six GP practices in the south of the Netherlands. Several process evaluation components from Baranowski and Stables (i.e. reach, dose delivered, fidelity, dose received (exposure and satisfaction), and barriers) were chosen as theoretical base for the process evaluation (Baranowski and Stables, 2000, Linnan and Steckler, 2002, Saunders et al., 2005). Table 1 shows an overview of

Reach

On behalf of the six GP practices, 1825 screening lists were sent to community-dwelling frail older people (≥70 years) (see Fig. 1). The response rate was 80.9% (n = 1477). Of those, who have signed the consent form (n = 569) 37.6% (n = 214) were frail according to the GFI score  5. Finally, 194 frail older people were included in the study. Of these, 44.8% (n = 87) were male and 46.4% (n = 90) lived alone (versus living together, n = 104). Most people (60.3%, n = 117) had no or lower than average education

Discussion

The aim of the process evaluation was to provide insight into the extent to which the interdisciplinary care approach PoC is implemented as planned. Furthermore, healthcare professionals’ and frail older people's experiences regarding its feasibility were evaluated. From the perspective of the healthcare professionals, the PoC approach provided a useful structure for the delivery of geriatric primary care and increased the attention to preventive treatment. Frail older people were satisfied, as

Conclusion

To prevent disability in community-dwelling frail older people, complex interventions conducted by an interdisciplinary primary care team are needed, involving individualized assessment, tailor-made interventions and long-term follow-up. With regard to integrated care, nurses are recommended as case managers to plan, organize and monitor the care process and to facilitate cooperation between professionals. The PoC approach is appreciated by healthcare professionals and frail older people and

Acknowledgements

The authors would like to thank participating older people and healthcare professionals, the members of the research group: Walther Sipers (Orbis Medical Centre) Lilo Crasborn (MCC Omnes), Simone Denis (MCC Omnes), Marlou Wolters (MCC Omnes), Jill Bindels (Maastricht University) and their research assistants: Floor Koomen, Ine Hesdahl and Astrid Dello.

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