Background
Methods/design
Overview
Prevention and Reactivation Care Program | Hospital care with follow-up care | Hospital care without follow-up care | |
---|---|---|---|
Hospital care | Identification of vulnerable elderly patient within 48 h Assessment of risk factors for functional decline Start reactivation treatment within 48 h Clinical geriatrician Geriatric nurses | Start reactivation treatment after discharge No specific identification instrument | Start reactivation path after discharge |
Hospital replacement care | Prevention and Reactivation Centre Part of treatment plan Continuation of (in hospital started) treatment focused on six domains of functional status Availability of (para)medical disciplines | Hospital replacement care Admission is patient's choice Care facility with option for treatment No structured treatment plan, but separate elements Limited number of (para)medical disciplines | Hospital replacement care not available |
Home care | Geriatric care chain agreements with general practitioner and home care Case management with geriatric expertise | Follow-up care by home care organizations (not specialized in geriatrics) | Follow-up care by home care organizations (not specialized in geriatrics) |
Multidisciplinary approach | Weekly multidisciplinary team meeting Treatment and care focused on medical condition and functioning in six domains (i.e. physical, mental, social, financial, home, and care) Goal-oriented approach | Key professional is responsible for treatment and interdisciplinary consults Discussion and collaboration focused on medical condition | Key professional is responsible for treatment and consults Discussion and collaboration focused on medical condition |
Patient | Patient oriented integrated treatment plan Discussion treatment with patient during entire treatment path Problem solving | Separate treatment plans Treatment coherence determined by patient | Separate treatment plans Treatment coherence determined by patient |
Informal caregiver | Part of treatment plan | Individual choice | Individual choice |
Community involvement
Roles and responsibilities
Intervention | PReCaP Core Staff |
---|---|
Hospital | |
Identification of patient at risk within 48 h after admission | Research nurse |
Assessment of risk factors for functional decline | Research nurse |
Consult with patient and relatives to discuss vulnerability and risk factors | Casemanager or geriatric nurse |
Biweekly Multidisciplinary Team Meeting: | Geriatrician |
• Analysis of the function diagnosis in relation to the medical diagnosis | Geriatric nurse |
• Design GAS care plan including advice for additional treatment aimed at functional preservation | Nurse practitioner |
Social worker | |
Transfer nurse | |
Casemanager | |
Geriatric consultation | Geriatrician |
Geriatric nurse | |
Casemanager | |
Transfer nurse | |
Interdisciplinary consultation, e.g. psychiatrist, psychologist, physiotherapist, occupational therapist, dietician, behavioral consultant | Geriatrician |
Casemanager | |
Support and provide treatment to informal caregiver (optional) | Social worker |
Review prognosis and discharge destination (in some cases register patient at hospital replacement care facility) | Psychologist |
Geriatrician | |
Geriatric nurse | |
Nurse practitioner | |
Social worker | |
Transfer nurse | |
Casemanager | |
Weekly telephone consultation informal caregiver | Casemanager |
Hand out flyer 'PReCaP Recovery Team' to patient | Casemanager |
Exit interview with patient and informal caregiver | Transfer nurse |
Hand out flyer 'Prevention and Reactivation Centre' to patient (if transfer to PRC) | Transfer nurse |
Handover GAS care plan to physician hospital replacement care facility | Casemanager or geriatrician |
Home visit and support after hospital discharge until six months after hospital admission, including optional therapy | Casemanager |
Prevention and Reactivation Centre | |
Admission to PRC (including GAS care plan/medical handover) | Nurse practitioner |
Review GAS care plan | Nursing home physician or nurse practitioner |
Physical examination | Nursing home physician |
Intake patient/informal caregiver | Nurse |
Weekly Multidisciplinary Team Meeting: | Nursing home physician (coordinator) |
• First MTM after one week admission PRC | Nurse practitioner Casemanager Psychiatrist (in consultation) |
• Review progress and adjust GAS care plan | Social worker (in consultation) |
• Casemanager home care attends MTM in week 9 | Clinical geriatrician (in consultation) |
Introduction and intake patient | Nurse |
Treatment according to GAS care plan | Consulted disciplines |
If needed additional treatment by PReCaP recovery team and other disciplines if indicated, e.g. behavioral therapist, dietician, music therapist, dance therapist, visual arts therapist | Casemanager |
Hand over diary to patient (incl. therapy appointments and treatment information) | Nurse |
Support with activities according to diary | Nurse |
Specialized nursing home care within the socio-therapeutic environment, e.g. psychologist, physiotherapist (3 times a week), occupational therapist, speech therapist, dietician, behavioral therapist, music therapist, dance therapist, visual arts therapist, social worker | Casemanager |
Review medication use | Nursing home physician |
Support informal caregiver | Psychologist Casemanager |
Assessment of Motor and Process Skills | Occupational therapist |
Before discharge home visit (in week 9) | Occupational therapist |
If needed consultation external expertise, e.g. ophthalmologist, otolaryngologist, (orthopedic) surgeon, psychiatrist, neurologist, dermatologist, rehabilitation specialist | Nursing home physician |
If needed short term admission to psychiatric hospital or re-admission to hospital | Nursing home physician |
Hand out flyer 'PReCaP route after discharge' | Casemanager |
At discharge: write-up report GAS care plan, including advice additional treatment aimed at function preservation in the home environment | Nursing home physician (coordinator) |
Nurse practitioner Casemanager Psychiatrist (in consultation) | |
Social worker (in consultation) | |
Clinical geriatrician (in consultation) | |
At discharge: write-up discharge letter | Nursing home physician Nurse practitioner |
At discharge: write-up handover | Involved disciplines |
At discharge: handover care plan to general practitioner | Casemanager |
If home care after PRC discharge: intake casemanager homecare in the presence of casemanager PReCaP ('warm handover') | Casemanager |
Setting and administrative structure
Process of care
Identification and screening procedure
Key interventions
Follow-up treatment at the prevention and reactivation centre
Additional follow-up treatment routes
Goal attainment scaling
Domain | Functional State Score | ||||
---|---|---|---|---|---|
Totally functionally dependent (1-2) | Regularly functionally dependent (3-4) | No help needed, only guidance (5) | Functionally independent with adjustments and/or aids (6) | Independent (7) | |
Somatic | |||||
Cognition | |||||
Personality | |||||
Emotional and rational experiences | |||||
Social environment | |||||
Life history and/or trauma |