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Proactive Primary Care Approach for Frail Elderly (U-PROFIT)

Target Population

Frail Elderly

Country

Netherlands

Year Established

2010

HOW IT WORKS

U-PROFIT provides interventions that enhance the care of frail older patients in general practice. Programming includes a screening and monitoring intervention using routine health care data, and nurse-led multidisciplinary interventions. Potential enrollees are identified by software applied to electronic medical records using an algorithm based on polypharmacy and a frailty assessment of diagnoses and functional deficits. Providers can also refer patients directly to the program. Registered elderly care nurses play a central role: They review data on individuals referred to the program, reach out to suitable participants to collect more detailed data and obtain their consent to enter the program, visit patients at home and complete a standardized comprehensive geriatric assessment, and work with general practitioners (GPs), patients, and their caregivers to define specific health and social care needs. A structured toolkit is used to create an individualized care plan, which the elderly care nurse helps to implement with relevant providers in a multidisciplinary team. This team can be comprised of  pharmacists, geriatricians, mental health providers, well-being workers, and informal caregiver coordinators. The nurse also works closely with the patient and caregiver on self-management and engagement.

IMPACT

The program started as a pilot demonstration in 2010. A randomized controlled trial conducted during the pilot phase produced encouraging results. The program has since been scaled up and spread across regions of the Netherlands. The program will be evaluated along with other European programs using standardized metrics and a common research design as part of SELFIE (Sustainable Integrated Care Models for Multi-morbidity: Delivery, Financing and Performance) a Horizon2020 EU project.

WHAT’S INNOVATIVE

For providers

The program introduces a new provider, the registered elderly care nurse, to the local health system. GPs also play a central role as members of the multidisciplinary team led by the elderly care nurse.

For patients/caregivers

Frail elders have home access to an elder care nurse, who works closely with them and their caregivers. Patients and caregivers often are included in multidisciplinary care team meetings.  

GOVERNANCE

Primary care centers provide leadership and collaborate with home care organizations, nursing homes, and the municipality. Eight primary care centers have formed collaborations within and beyond health care. These collaborations take various forms - some use registered practice nurses as elderly care nurses while others use district nurses. The predominant health insurer in the Utrecht region, Zilveren Kruis Achmea, covers about half the population and has been involved in U-PROFIT since the program’s early stages.

SUPPORTIVE POLICIES

Elder care nurses are a new professional role. These nurses are already experienced in providing elderly care and receive special training for the purpose of implementing the U-PROFIT program interventions. Currently, U-PROFIT is financed through an implementation grant from the Netherlands Organisation for Health Research Development (ZonMw), two elderly care modules, one for case management and the other for primary care collaboration (temporary incentives to stimulate innovation by the health insurer), and internal investments by the primary care centers.

Publication Details

Publication Date: November 9, 2018