Background
Methods
Study design and participants
Experts
Older people
Ethics
Interview topics
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Goal, setting, target population, initiator
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Methods used in the initiative to identify frail older people or older people at risk of frailty, and methods used to assess problems and risks. Since there is no consensus on the definition of frailty and its determinants [39], we adopted a broad interpretation. Initiatives were included in our study, regardless of how “frailty” was defined in the initiative
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Scope (i.e. health, wellbeing, participation, living circumstances etc.)
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Effectiveness of the initiative
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Follow-up of the initiative (such as preventive programmes, care plans and case management)
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Experienced alignment between initiatives on early detection and intervention
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Overall strengths and weaknesses of initiatives on early detection and intervention
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Possibilities for improvement of existing initiatives
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Potential personal experiences with early detection and intervention
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Views (their own and by proxy of the people they visit) on early detection and intervention
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Preferences with regard to early detection and intervention (e.g. setting, kind of professional, scope and approach)
Data analysis
Results
General characteristics of categories of initiatives on early detection and intervention in the Netherlands
Goals
Setting, target population, and initiator
Instruments and scope
Cost-effectiveness
Follow-up
Overall experiences and views of experts on early detection and intervention
Definition of frailty and identification of frail older people
From the start, we were in two minds about this project. In retrospect, it’s always more clear than during the project itself. So, looking back at what we wrote in the project proposal, it’s already there. It says: we aim to focus on frail older people, so older people living in disadvantaged neighborhoods and the oldest old with co-morbidity; but those two groups are completely different! (Researcher 1)
Scope of initiatives
Such a screening list is fine, but the way I see it, it also depends on the trust you put in people and the relationships you can build. That is, that you make the effort to get a full picture of a person’s situation. (Community Nurse 1)
And when we come in, then you have a totally different atmosphere. Then you get those problems out on the table. (VEA 1)
Alignment of initiatives
There are so many agencies willing to support older people: Humanitas [social services and community building organisation], the Salvation Army, De Wering [organisation of social workers], community centres, senior citizens’ associations, residential homes with their own volunteers. This makes it very difficult for older people to know where to ask for help. […] There are so many people who believe ‘older people are lonely, we need to do something about that’, and start with another service. And I think, ‘there are so many services already. What about integrating all of them, before starting up something new’. (VEA 2)
There are always two sides to this kind of things. One, regarding cooperation, it is not always easy for disciplines that have to work together, to look past the end of their noses. Two, daily organizational hassles: how do you manage to meet? The fact that one discipline is being paid for attending meetings while another is not, doesn’t make it any easier. That is not conducive to getting things done. (Researcher 2)
Effectiveness of the initiatives
What you want is evidence, good evidence. Five years ago we started these projects because our hearts told us: this should be the right type of care. If you’d ask me now, ‘is this good care?’, then I’d say ‘yes, it is’. After seeing the evidence, whether I need to adjust my ideal, I do not know. Everyone is still very much preoccupied with their ideals; ideologically, it should be like this. (Researcher 3)Within healthcare, but also in the social domain, you must know what interventions are effective. With heart surgery, you know: it works or it does not. But in the social domain to achieve that goal is tricky, assuming you have a clear, well formulated goal and you also know: I will achieve this goal because I’m doing this and that. This causality is also a difficult issue. (Policymaker 1)
A grey head of hair, that appeals to them. And that’s why our motto is: for and by older people. It works, and not always bring in a professional. (Policymaker 2)
Follow-up to early detection
Screening for something for which there is no effective intervention makes no sense, and unfortunately, that’s true for almost everything. There are very few exceptions. (Researcher 3)
Experiences and views of older people on early detection and intervention
Category (based on setting) | Target population | Goal | Initiator | Health/social care professionals involved | Scope | Follow-up | Screening methods | Scale |
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Group 1: initiatives aiming to detect older people at risk of deterioration in order to provide preventive interventions
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Varies per initiative: target populations based on for example age, SES, health insurer, location of health care use | To prevent or early detect physical and psychological problems in (frail) older people | Varies per initiative: Home care organisation, municipal mental health care organisation, GP, nurse practitioner, community nurse | Varies per initiative: Community nurse, Municipal Health Services, (occupational) physician, community psychiatric nurse | Physical, psychological and social functioning | Provision of information and advice on lifestyle, preservation of independence and control. Referral to other professionals if necessary | Varies per initiative: For example: an instrument covering 3 domains: 1. Screening for frailty (Groningen Frailty Indicator); 2. Screening for health problems (Intermed) 3. Screening for wellbeing (Groningen Wellbeing Indicator) | Various locations were identified across the Netherlands. Per elderly health centre, a varying group of people was exposed to the initiative (e.g. a whole community; only people from certain GP practices; people affiliated with a specific health insurer) | |
All people in a municipality who are 75 years and older | To bring community services to the attention of older people and to detect unidentified problems | Volunteer from welfare/volunteer organization | Welfare/volunteer organization, professional elderly advisor | Health, wellbeing, living circumstances, social participation | Provision of advice on services that can facilitate self-reliance and participation | Screening instruments are often not used. In some municipalities, a questionnaire or list with topics regarding activities, social relations, mobility, finances, nutrition is used | Informative home visits are offered by local welfare organisations in various municipalities across the Netherlands. Within those municipalities, every person over 75 years is exposed | |
Group 2: initiatives aiming to detect problems (and needs) with regard to health and wellbeing in frail older people in order to optimize (current) delivery of health and social care
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Older people living at home, who are at high risk of frailty. Age categories differ per initiative, e.g. people aged 65 and over; people aged 75 and over. | To identify frail older people in the population, and provide proactive care if necessary | Primary care | GP, nurse practitioner, community nurse. Other health and social care professionals if necessary, according to the problems that are identified. | Physical, psychological and social functioning | Design and execute a personal care and support plan | Varies per initiative: Screening methods for frailty, e.g. GP registries, screening instruments such as Groningen Frailty Indicator. | At least 8 types of initiatives were identified that were practiced in various locations in the Netherlands. The initiatives included approximately 170 practices and approximately 16.300 (frail) older people were exposed to the initiatives | |
Screening instruments for problems and risks related to health, wellbeing and living circumstances, e.g. Resident Assessment Instrument, EASY-Care TOS | ||||||||
Patients over 65 who are at high risk for loss of function during hospitalisation | To prevent loss of function during and after hospitalisation | (Research) nurse in hospital | Geriatric nurse, transfer nurse, geriatrician, case manager. Other health and social care professionals if necessary, according to the problems that are identified | Preservation of functioning, self-reliance and quality of life | Delivery of proactive care during hospitalisation combined with coordinated after care after hospital discharge | Varies per initiative: ISAR-HP, VMS (for screening frailty). GAS-plan, geriatric assessment (for screening for problems and risks) | At least 2 types of initiatives were identified in hospitals in the south-west and north-west of the Netherlands. Based on these initiatives, a minimum of 500 older people were exposed to the initiatives | |
5. Initiative by health and social care professionals who visit older people at their homes [77] | Older people living at home who are frail or at risk of frailty | To early detect psychosocial problems and risks | Health and social care professionals who visit older people at their homes, e.g. nurse from a home care organization, VEA, community nurse | Professionals from municipal (mental) health care organization, nurse from a home care organization, VEA, community nurse | Psychosocial problems and risks (e.g. loneliness, depression, alcoholism, elderly abuse) | Referral to the required services for their psychosocial issues | Screening instruments are used by some professionals (e.g. the Geriatric Depression Scale, GDS). Professionals mostly use their “gut-feeling” | This initiative was identified in one area in the south-west of the Netherlands |
Varies per initiative: the community in general. Some of the initiatives are targeted at frail older people | To gain insight into the problems and needs in a community and facilitate people to keep control over their own lives | Community nurse (sometimes in combination with other professionals that are active in the community, e.g. social workers, district policemen) | Various health and social care professionals, according to the problems and needs that are identified | Various domains. For older people mainly health, wellbeing, safety and living situation | Provision of information, practical support, after care; referral to other professionals; facilitation of involvement of family caregivers | In some initiatives screening instruments are used. An “open conversation” without using any instruments is often preferred. | Initiatives by community nurses are offered in various neighbourhoods across the Netherlands | |
Older people needing help, who contacted the elderly organisation | To facilitate self-reliance by offering practical support and contacting professionals if necessary | Initiated by older person or someone in his social network | VEA, others professionals according to the problems and needs that are identified | Health, wellbeing, living circumstance, participation | Provision of advice and practical support | In some cases, a topic list is used, but screening instruments are mostly not used. An “open conversation” without using any instruments is preferred. | VEAs are active through elderly organisations or local welfare organisations in various municipalities across the Netherlands. | |
8. Home visits by municipalities (so-called “kitchen-table conversations”). [83] | Older people living at home who requested support from municipal services and facilities | To evaluate the extent to which older people are self-reliant and able to participate in society, the support they receive from their social network, and the care and support that would be necessary from the municipality. All intended to facilitate self-reliance and social participation. | Initiated by older person, possibly in consultation with professional | Several possibilities, but always commissioned by municipality: social care consultant of the municipality, employee from (social) welfare organization, client support organization, health care organization. | All life domains (e.g. living, working, income/debt, education, health, lifestyle, leisure activities, social activity, mobility, practical skills). | Provision of support from municipal social services (e.g. home care, adult day care services) if older people are not self-reliant or able to independently, or with the support from their social network, participate in society. | Varies per municipality, e.g. Self-reliance matrix (ZRM) and the Vitality Indicator | In principle in all municipalities in the Netherlands. However, due to large reforms of the long-term care system (that involve municipalities), not all municipalities are able to offer kitchen table conversations yet. |
Approach
I feel like the government thinks that all older people are unhealthy, have dementia, and I don’t know what else…That is not true. […] I think the government’s presentation of us older people is downright wrong. That’s a shame. That image has to change over there. We talk ourselves into it. (VEA 3)
Scope of initiatives
Setting of initiatives
What is very important, is the notion that ‘the elderly’ does not exist. Nor is there a standard solution. (VEA 4)