出版社：Utrecht University, Maastricht University, Groningen University
摘要：Background : Frail elderly often have multiple health problems that span the physical, psychological, and cognitive domains. This makes frail elderly depend on care and support services. Simultaneously, frail elderly in the Netherlands are being stimulated to live at home independently as long as possible. Frail elderly are often supported by several care providers, like informal caregivers, GPs, practice nurses, district nurses, neighbourhood teams, social workers, physical therapists, elderly care physicians, home care nurses for domestic help, and medical specialists (e.g., geriatricians). It is important that the care provision of frail elderly is integrated and that providers collaborate, in order to tackle the risk of fragmentation. As a response, different care programmes have arisen that provide integrated care for frail elderly. Aim : In the EU Horizon2020-funded project SELFIE, promising integrated care programmes in Europe were selected to evaluate. One of these programmes is the Care Chain Frail Elderly (CCFE) – an integrated care approach for frail elderly. The qualitative thick description of the programme sheds light on what the CCFE approach is, how it is being implemented in daily practice, and how different stakeholders reflect on the approach, so that future interventions can benefit from the barriers and facilitators of this programme. Methods : The information necessary for a qualitative description of CCFE was gathered through document analyses as well as qualitative interviews with 11 stakeholders (e.g. professionals, frail elderly and informal caregiver, insurance employees) from July through September 2016. The results were structured according to the six elements of the SELFIE conceptual framework for integrated care for multi-morbidity: service delivery, leadership and governance, workforce, technologies and medical products, information and research/monitoring and financing). Results : The CCFE is a proactive nurse-led intervention providing case management, care coordination, and multidisciplinary care team meetings to the frailest elderly. They use case finding for identification of frail elderly persons, relying strongly on the professional’s ability and less-so on standardised screening algorithms or questionnaires, as some other programmes in the field do. Furthermore, this programme is unique in that it actively involves the frail elderly and informal caregiver in the multidisciplinary team meetings. To cover the costs of the programme, an innovative payment scheme was piloted, namely a bundled payment for frail elderly care that covers all primary care costs irrespective of diagnosis. Barriers in delivering the programme pertain to the sustainability of financing and the challenges in collaboration between health- and social care. These findings will be elaborated on during the presentation. Conclusion : The CCFE is an intensive care programme for the frailest elderly living at home. Convincing results on the (cost-) effectiveness of this programme are needed to ensure sustainable financing. Accordingly, the insights gained in this qualitative study form the basis for setting up an empirical evaluation of the CCFE in the context of further SELFIE research.
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