The CareWell-programme for Community-dwelling Frail Elderly Persons.

Radboud University Medical Center536 enrolled

Overview

The purpose of this study is to investigate the effect of the CareWell-programme on overall functioning of community-dwelling frail elderly persons. Furthermore, the total costs and the cost-effectiveness of the CareWell-programme, in comparison with regular medical care, will be studied.

Study Type

INTERVENTIONAL

Allocation

NON_RANDOMIZED

Purpose

HEALTH_SERVICES_RESEARCH

Masking

NONE

Enrollment

536

Conditions

Overall Functioning Incremental Cost-effectiveness Ratio

Interventions

The CareWell programmeOTHER

The CareWell programme contains the following components: * multidisciplinary primary care teams * working with proactive care plans integrating cure, care and welfare * advanced care planning (e.g. recording limitations of treatment, non-resuscitation decisions) * medication review * case-management * guidelines for consultation of in-hospital geriatric experts * guidelines for transfers from primary care to home-based facilities and hospital and back * practice guidelines for management of common geriatric conditions

Eligibility

Sex: ALLMin age: 70 Years

Medical Language ↔ Plain English

Inclusion Criteria: * Frail community dwelling elderly patients aged 70 years or above. Frailty is determined with a two-phase screening instrument. Exclusion Criteria: * Non-frail elders * Patients in palliative or end-of-life stages of disease * Patients residing in long-term care facilities (care homes and nursing homes) * Patients already enrolled in specific dementia-related case-management programmes who lack other health-related problems * Patients not speaking or understanding the Dutch language

Locations (10)

Huisartsengroep Milbergen (van der Ligt/ Krijgsman), Oude Gracht 16

Beek-Ubbergen, Netherlands

Gezondheidscentrum de Kroonsteen, Schoolstraat 8

Malden, Netherlands

Gezondheidscentrum de Vuursteen, Prinsenweg 6

Molenhoek, Netherlands

Outcomes

Primary Outcomes

Overall functioning

Overall functioning is measured with the Katz-15 questionnaire. Katz-15 is embedded in the minimal data set (MDS). This MDS is used by all research projects of the Dutch National Program on Elderly Care

Time frame: 18 months

Incremental cost-effectiveness ratio (ICER)

Time frame: 18 months

Secondary Outcomes

Perceived quality of life

Perceived quality of life is measured with the RAND-36 questionnaire. RAND-36 is embedded in the minimal data set (MDS). This MDS is used by all research projects of the Dutch National Program on Elderly Care

Time frame: 18 months

Psychological well-being

Psychological well-being is measured with the RAND-36 questionnaire.

Time frame: 18 months

Social functioning

Social functioning is measured with the RAND-36 questionnaire.

Time frame: 18 months

Perceived health

Perceived health is measured with the RAND-36 questionnaire abd Cantril's Self Anchoring Ladder. Both RAND-36 as Cantril's Self Anchoring Ladder are embedded in the minimal data set (MDS).

Time frame: 18 months

Utility

Utility is measured with the EQ-5D questionnaire. EQ-5D is embedded in the minimal data set (MDS).

Time frame: 18 months

Health care consumption

Health care consumption including hospital resource consumption, unplanned GP care (evenings, nights and weekends), home care, temporary or permanent admission to a residential care home, temporary or permanent admission to a nursing home, day care, visits to outpatients'clinics.

Data from ClinicalTrials.gov

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