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The frail elderly person at the centre of cohesive care.


- candidate number6872
- NTR NumberNTR2160
- ISRCTNISRCTN wordt niet meer aangevraagd.
- Date ISRCTN created
- date ISRCTN requested
- Date Registered NTR12-jan-2010
- Secondary IDs311080301 ZonMw
- Public TitleThe frail elderly person at the centre of cohesive care.
- Scientific TitleThe frail elderly person at the centre of cohesive care.
- ACRONYM
- hypothesisVulnerable 65+ years persons who participate the Geriatric Care Model will experience a better Quality of Life compared to elderly persons receiving care as usual.
- Healt Condition(s) or Problem(s) studiedFrailty
- Inclusion criteriaPersons 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 criteria1. Being institutionalized;
2. Living outside Amsterdam-Zuid/Amstelveen and Westfriesland, while the GP works in this area;
3. Intellectually disabled;
4. Less consciousness.
- mec approval receivedno
- multicenter trialno
- randomisedyes
- masking/blindingNone
- control[default]
- groupParallel
- Type2 or more arms, randomized
- Studytypeintervention
- planned startdate 1-dec-2009
- planned closingdate1-dec-2012
- Target number of participants1200
- InterventionsGERIATRIC 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 nurses; 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. Approximately 40 general practices, home care organisations, residential and nursing homes, social service centres, mental health institutions in the participating regions will actively take part in recruitment and the provision of care and support.

All participating general practices will eventually work according to the GCM, but the starting moments are phased and determined at random. In total, 40 general practices will be randomised in 4 tranches of 10 practices with starting dates that are spaced 6 months apart. During the waiting period, standard care is provided.
- Primary outcomeQuality of life of the elderly (SF12).
- Secondary outcomeEVALUATION 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).
- TimepointsBaseline measures will be taken directly after inclusion of the elderly person. Follow-up measures are taken 6, 12, 18 and 24 months after baseline.
- Trial web sitewww.ouderennet-vumc.nl
- statusplanned
- CONTACT FOR PUBLIC QUERIES M. Nadort
- CONTACT for SCIENTIFIC QUERIES Danielle Jansen
- Sponsor/Initiator VU University Medical Center
- Funding
(Source(s) of Monetary or Material Support)
ZON-MW, The Netherlands Organization for Health Research and Development
- PublicationsN/A
- Brief summaryObjective:
The primary aim is that the geriatric care model improves quality of life of the older frail participating persons as compared to care as usual.
The secondairy aims are that the geriatric care model leads to:
1. More maintance of functional ability, a decrease in unmet care needs, a decrease in acute hospital admissions among the older frail participating persons as compared to care as usual;
2. Among the informal caregivers of participating older frail persons: a reduction in perceived care load and a better quality of life as compared to care as usual;
3. High quality care and efficient care.

STUDY DESIGN
A stepped wedge cluster randomised trial. Baseline measures will be taken directly after inclusion of the elderly person. Follow-up measures are taken 6, 12, 18 and 24 months after baseline. All participating general practices will eventually work according to the GCM, but the starting moments are phased and determined at random. In total, 40 general practices will be randomised in 4 tranches of 10 practices with starting dates that are spaced 6 months apart. During the waiting period, standard care is provided. Six monthly follow up measurements (process and outcomes) are scheduled during two years.

STUDY POPULATION
1. 1200 frail elderly persons 65 years of age or older who live idependently. Frail persons will be identified by screening (medical files) and case finding by health care professionals of Ouderennet VUmc & partners;
2. If present, the (approximately 850) primary informal carer of persons in the frail persons will be approached for participation in the project.

OUTCOMES
A. EVALUATION OF EFFECT
(1) Elderly persons: (a) Quality of life (SF-12); (b) Self-sufficiency and functioning (Katz ADL), (c) care needs (CANE), (d) acute hospital admissions. (2) Informal carers: (a) Perceived care load (MDS-item), (b) quality of life (SF12). (3) Professionals and organisation: Quality of care (ACOVE and RAI indicators).
B. EVALUATION OF PROCESS
Degree to which all elements of the Geriatric Care Model are applied.
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.
C. ECONOMIC EVALUATION
(Cost of) care usage (MDS items complemented by care registrations).
- Main changes (audit trail)
- RECORD12-jan-2010 - 20-jan-2010


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