Electronic supplementary material
The online version of this article (doi:10.1186/1472-6963-12-85) contains supplementary material, which is available to authorized users.
The authors declare that they have no competing interests.
JS drafted the manuscript. JS and EMC wrote the protocol for the Medical Ethics Committee. BB, MvJ, RH, GtR, SR en EMC critically reviewed the manuscript and protocol for the Medical Ethics Committee. SR drafted the research proposal. BB, RH and EMC reviewed the research proposal that was sent to the funding organization. RH was involved in the methodological construct of the study. All authors read and approved the final version of the manuscript
Functional decline in community-dwelling older persons is associated with the loss of independence, the need for hospital and nursing-home care and premature death. The effectiveness of multifactorial interventions in preventing functional decline remains controversial. The aim of this study is to investigate whether functional decline in community-dwelling older persons can be delayed or prevented by a comprehensive geriatric assessment, multifactorial interventions and nurse-led care coordination.
In a cluster randomized controlled trial, with the general practice as the unit of randomization, 1281 participants from 25 general practices will be enrolled in each condition to compare the intervention with usual care. The intervention will focus on older persons who are at increased risk for functional decline, identified by an Identification of Seniors at Risk Primary Care (ISAR-PC) score (≥ 2). These older persons will receive a comprehensive geriatric assessment, an individually tailored care and treatment plan, consisting of multifactorial, evidence-based interventions and subsequent nurse-led care coordination. The control group will receive 'care as usual' by the general practitioner (GP). The main outcome after 12 months is the level of physical functioning on the modified Katz-15 index score. The secondary outcomes are health-related quality of life, psychological and social functioning, healthcare utilization and institutionalization. Furthermore, a process evaluation and cost-effectiveness analysis will be performed.
This study will provide new knowledge regarding the effectiveness and feasibility of a comprehensive geriatric assessment, multifactorial interventions and nurse-led elderly care in general practice.
Unrestricted grant 'The Netherlands Organisation for Health Research and development' no 313020201