patients with DM2, COPD and chronic cardiovascular diseases and the presence of at least one other chronic condition
Conditions
Interventions
Patients will be seen by the practice nurse during their regular scheduled consultation follow up of their chronic healthcare plan and a discussion of the results of the primary care functioning scale
Sponsors
ZonMw
Eligibility
Inclusion criteria
Inclusion criteria: Patients in primary care age 65 years or older with the inlcusion of two or more chronic medical conditions
Exclusion criteria
Exclusion criteria: Patients who are terminal ill, receive palliative care, have severe psychiatric disorders (e.g. severe depression, psychosis) and patient who are not able to speak, read or write in Dutch
Design outcomes
Primary
| Measure | Time frame |
|---|---|
| perceived health and functioning measured by the primary care functioning scale (PCFS) | — |
Secondary
| Measure | Time frame |
|---|---|
| Experience and actions derived from the results of the PCFS will be explored during a 15-minutes interview with the patient by telephone. Self-efficacy is evaluated by the General Self-Efficacy Scale. Expectations about the course and prognosis of the chronic disease will be assessed by the Illness Perception Questionnaire (IPQ-R). Course and outcome of performance indicators in DM2, COPD and heart failure care. For DM2 we will use the available assessments of HbA1c, blood pressure, cholesterol levels (LDL), renal functioning (eGFR) and body mass index (BMI). For COPD we will use The available measurements of smoking behavior, and FEV1 and FVC measured by spirometry. In patients with heart failure we are interested in blood pressure, cholesterol levels (LDL), renal functioning (eGFR), and body mass index (BMI). These disease specific outcome measures, coming from routine control consultations, will be extracted from the electronic medical health record. Medical consumption is assessed a short questionnaire after 3 months. Patient satisfaction with the use of the PCFS and patient satisfaction with the feedback of the results of the PCFS will be rated on a 5-point Likert-type scale (extremes labelled as ‘not at all’ and ‘very much’).Baseline characteristics, such as age, gender, marital status, social economic status (employment and level of education), source of income, and working hours are already incorporated in the PCFS questionnaire. | — |
Contacts
Public ContactSimone Postma
Radboudumc
Outcome results
None listed