Finding and Follow-up of the Frail

The primary care approach Finding and Follow-up of the Frail (FFF) aims to target frail community-living older persons. The main objectives of the FFF approach are: (1) the early case finding of independently-living frail older people, (2) the establishment of an integrated primary care system for these older persons (consisting of collaboration among professionals with different occupational backgrounds led by a GP), (3) preventing (repeated) hospital and nursing home admissions, and (4) enhancement of well-being, health-related quality of life, self-management abilities, and support systems for older persons. The multidisciplinary setting enables the development of the role of the elderly care physician and geriatric nurse within the primary care setting, a new approach in the Netherlands. In more detail, the following key elements are incorporated in the FFF approach.

  1. Case finding

In order to find potentially frail community-dwelling older persons of 75 years and over, the GP makes a selection of older adults based on a ‘sense of alarm’. These selected persons are then visited at home by the geriatric nurse or practice nurse and screened on frailty by means of the Tilburg Frailty Indicator (TFI). The TFI is a 15-item questionnaire that assesses frailty in the physical, psychological and social domain (Gobbens, van Assen, Luijkx, Wijnen-Sponselee, & Schols, 2010). This instrument was developed based on the definition of frailty as stated by Gobbens, Luijkx, Wijnen-Sponselee and Schols (2010, p. 175), namely ‘Frailty is a dynamic state affecting an individual who experiences losses in one or more domains of human functioning (physical, psychological, social), which is caused by the influence of a range of variables and which increases the risk of adverse outcomes’. Scores on the TFI range from 0 to 15 and older persons with a TFI ≥ 5 are identified as frail. Moreover, the practice nurse or geriatric nurse will perform physical measures or additional interviews with the older person when necessary (e.g. mini–mental state examination (MMSE) to assess cognitive functioning). Hence, it may happen that a person is not frail according to the TFI (score ≤ 4) but is considered frail based on examination of the nurse. We consider these additional interviews important because it is stated that the TFI cannot replace other interviews and measures of frailty in all situations (Gobbens & van Assen, 2012).

  1. Multidisciplinary consultation and care plan

The home visits for the benefit of case finding are followed by a discussion of results with the elderly care physician and afterwards feedback information is provided to the GP. The case of each older person is discussed in multidisciplinary consultation. An inventory of other relevant health care professionals is made and these professionals are invited to attend the consultation. They involve professionals in the care and treatment of patients (e.g.elderly care physician, physiotherapist, psychologist), as well as professionals in the field of welfare when necessary. The GP leads the multidisciplinary consultation and the team of involved professionals. A care plan is established and recorded by means of the SFMPC-model of reporting on Somatic, Functional, Social, Psychological, and Communicative indications for each individual older person. Agreements are made regarding follow up (i.e. case management), and persons’ cases are discussed at least once a year. Specific protocols for patient referral are established. For example, older persons are asked to identify preferred health care organizations and professionals (e.g. physiotherapist) in the fields of care and welfare. These preferred professionals are approached by the GP, elderly care physician, or practice nurse. The professionals provide feedback information about patient care to the GP and/or elderly care physician.

  1. Medication review

Older persons’ medicines are systematically and critically examined in a medication review. An important aspect of multidisciplinary consultation is the discussion of prescribed and over-the-counter medications used by these older people. The most recent overview of medications used by the older person, and experiences with medications, are discussed with the person (and informal caregiver/relatives). Possible actions discussed in multidisciplinary consultation include

  • Visitation of the older person by the elderly care physician to provide additional information about medications,
  • The GP’s discussion of the person’s case history with the pharmacist, and
  • The establishment of agreement about medication use between the GP and specialized/hospital care in order to agree upon the use of medications.
  1. Elderly care physician

The elderly care physician plays an important role in the care process for the older persons. Next to being present to the multidisciplinary consultations, the GP can obtain advice from the team’s elderly care physician on several issues, e.g. depression and apathy, somatic or geriatric indications, and problem analysis in case of multimorbidity. Multimorbidity is defined as the co-occurrence of two or more chronic conditions within one individual (van den Akker, Buntinx, & Knottnerus, 1996). The GP and the elderly care physician discuss whether one or several consultations are needed to assess each older person’s relevant healthcare needs. The elderly care physician employs the following methods:

• Assessment of the patient’s medical history;

• Anamnesis and examination (e.g. assessment of the needs of the patient and his/her informal caregiver; assessment of somatic, functional, social, psychological, and communicative areas of special interest; review of medication);

  • Listing and analysis of problems;
  • Reaching agreement with the GP on the care plan, communication with the patient and informal caregiver/relatives, and evaluation; and
  • Provision of feedback to the GP.

In addition, the elderly care physician and practice nurse or geriatric nurse work as a team to coordinate care for general practice patients. Consultations are planned regularly. When necessary, other health and social care professionals (e.g. palliative care nurse) are involved.

Study evaluation

The longitudinal evaluation study has a mixed methods design in which a combination of quantitative and qualitative research methods will be employed in order to evaluate the effects, processes and costs of the FFF approach. The study has a quasi-experimental design with a pretest and posttest, i.e. the effects will be measured before and after the study (D. T. Campbell & Stanley, 1963; Shadish, Cook, & Campbell, 2002). The effects on outcome measures will be assessed at baseline (T₀) and 12 months thereafter (T₁). Moreover, the study includes an intervention and control group. A challenge in quasi-experimental designs is to reduce the risk of treatment selection bias, i.e. preexisting differences in characteristics between the intervention and control group due to the absence of random assignment. In order to acquire approximately unbiased estimates of the effects, the most important covariates should be balanced between intervention and control groups (Stuart & Rubin, 2008; Stuart, 2010). In this study we use one-to-one matching in which each individual participant in the intervention group will be matched to one participant in the control group with the same values of the key covariates, namely sex (male/female), frailty score (exact score) and educational level (high or low). The target population of the study consists of older persons (aged 75 years and over) as well as involved healthcare professionals. The research proposal has been reviewed by the medical ethics committee of the Erasmus Medical Centre in Rotterdam, the Netherlands (study protocol number MEC-2014-444).