frailty
Conditions
Interventions
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 nur
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.
Sponsors
VU University medical center
Eligibility
Inclusion criteria
Inclusion criteria: Persons 65 years or older with multiple conditions and who may be, partly as a consequence of this condition, vulnerable. These persons may experience insufficient aligment, management and continuity in care, risks due to their medication utilisation. We made this condition ready for use in the following way: 3 or more chronic conditions, or long term use of 5 or more types of medication during the previous half year or two or more referals to specialists during the previous half year.
Exclusion criteria
Exclusion criteria: 1. Being institutionalized; 2. Living outside Amsterdam-Zuid/Amstelveen and Westfriesland, while the GP works in this area; 3. Intellectually disabled; 4. Less consciousness.
Design outcomes
Primary
| Measure | Time frame |
|---|---|
| Quality of life of the elderly (SF12). | — |
Secondary
| Measure | Time frame |
|---|---|
| EVALUATION OF EFFECT 1. Elderly persons: A. Self-sufficiency and functioning (Katz ADL); B. Care needs (CANE); C. Acute hospital admissions. 2. Informal carers: A. Perceived care load (MDS-item); B. Quality of life (SF12). 3. Professionals and organisation: A. Quality of care (ACOVE and RAI indicators). EVALUATION OF PROCESS 1. Degree to which all elements of the Geriatric Care Model are applied; 2. 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. ECONOMIC EVALUATION (Cost of) care usage (MDS items complemented by care registrations). | — |
Contacts
Public ContactM. Nadort
Outcome results
None listed