frailty, multimorbidity, complex care needs, daily functioning, quality of life. kwetsbaarheid, multimorbiditeit, complexe zorgbehoefte, dagelijks functioneren, kwaliteit van leven.
Conditions
Interventions
1. Group A: Utrecht Periodic Risc Identification and Monitoring (UPRIM).
UPRIM is a method adapted for elderly care also known in the literature as panel management. It entails preventive identifica
functional decline, falling, mood and loneliness, urinary incontinence, malnutrition, visual impai
Sponsors
University Medical Center Utrecht
P.O. box 85500
3508 GA Utrecht
088 75 555 55
Eligibility
Inclusion criteria
Inclusion criteria: The target group of this project is made up of potentially frail older people in general practice setting, who are defined as persons of 60 years and older with: 1. Multimorbidity (defined as a moderate-to-high frailty index score, which is a reflection of the proportion of health deficits present.), AND / OR; 2. Polypharmacy (defined as the actual chronic use of 4 or more different medications), AND / OR; 3. A care gap in primary care of > 3 years, except for the yearly influenza vaccination.
Exclusion criteria
Exclusion criteria: 1. Terminally ill patients; 2. Patients living in or on a waiting list for an elderly home or nursing home.
Design outcomes
Primary
| Measure | Time frame |
|---|---|
| The primary outcome parameter is change in daily functioning. General functioning (ADL and IADL) is measured with the Katz 15 questionnaire, which is included in the minimal data set (MDS), the questionnaire used in this project. | — |
Secondary
| Measure | Time frame |
|---|---|
| 1. Quality of life, as registered with the RAND-36, partially included in the MDS; 2. Health care consumption, as expressed in: A. Number of ‘elective’ admissions to hospitals, nursing homes and elderly homes; B. Number of emergency department visits and ‘emergency’ admissions to hospitals, nursing homes and elderly homes; C. Number of contacts with the GP’s surgeries, outside the regular hours; D. Number of contacts with the healthcare assistant, the GP, the general practice assistant and the GNPC; E. Medication use, dysfunctional and functional polypharmacy; F. Consultation with other primary carers (General Social Work, elderly care, physical therapy, homecare). 3. Mortality, as registered in the EMR of the GP, and confirmed by dead certificates of the municipal administration (gemeentelijke basisadministratie); 4. Cost-effectiveness analysis (CEA). For the CEA, the ratio of differences in the main outcome measure - (I)ADL - between the three groups and differences in costs will be analyzed; 5. Patient satisfaction with -changes in- primary health care. Patient satisfaction will be measured in the MDS; 6. Comparison of frailty index courses between groups, and particular attention to the proportion of patients with polypharmacy, multimorbidity and a care gap of > 3 years, and the correlation between the frailty index score and daily functioning and quality of life; 7. Time spent on informal caring and burden of care for informal carer; health status and quality of life of informal carer. | — |
Contacts
Public ContactC.I.M. Heijst, van
Postbus 8605
Outcome results
None listed