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A model for the evaluation of integrated care approaches for frail older people


Lotte Vestjens ,

Jane Murray Cramm,

Anna Petra Nieboer


Background: Integrated care has emerged as a strategy to transform current primary care systems in order to deliver better care for community-dwelling older people. There is, however, large variability in the degree of effectiveness of integrated care approaches. An explanatory model of how integrated care affects outcomes is essential. The objective of the study is to present a theoretical model to facilitate the evaluation of integrated primary care approaches for frail community-dwelling older people and understand the underlying mechanisms explaining their effectiveness.

Theoretical model: The model is built on important elements of integrated primary care approaches which are aimed at improving quality of care and well-being of frail community-living older people. Integrated care involves the implementation and integration of multiple elements, which may hinder systematic and sound evaluation of integrated care approaches in terms of processes and effects. Therefore, it is necessary to develop a theoretical model in which core elements are defined, the assumed processes underlying the effects are clarified, and the expected outcomes are selected. The proposed theoretical model incorporates various interrelated elements of integrated care approaches for older people, such as proactive case finding of frail adults in the community, case management, medication review, self-management support and working in multidisciplinary teams. Efforts to improve primary care for frail older patients should integrate these promising components in order to assure that active, informed older patients can interact productively with their prepared, proactive primary care practice team members. Earlier research has shown that cognitive and behavioral components of health care professionals and patients drive effectiveness in terms of productive patient-professional interactions and well-being. The various concepts of the model are explained hereafter.

Quality of integrated primary care

- Proactive case finding: Integrated primary care for older people involves proactive case finding of frail adults living independently in the community. Case finding by means of assessing frailty in the physical, psychological and social domain is an important aspect of proactive care delivery in this older population.

- Case management: Coordination tasks need to be assigned to an individual (i.e. case manager) that is responsible for guiding the patient through the care process in an efficient, effective and adequate manner.

- Medication review: Frail older persons’ medicines are systematically and critically examined in a medication review. The most recent overview of prescribed and over-the-counter medications used by the older person and experiences with medications are discussed.

- Self-management support: Different types of self-management support interventions need to be incorporated, such as skill building, educational materials, personal coaching and an individualized care plan.

- Multidisciplinary teams: A strong team of professionals with different occupational backgrounds is one of the core elements of integrated primary care. Cases are discussed in multidisciplinary consultations.

Cognitive and behavioral components

- Behaviors and cognitions of frail community-living older people: Individuals take an active role in realizing well-being and aim to enhance their life situation by optimizing the universal goals of well-being. Empowered patients that are effective self-managers are better equipped to control chronic conditions and to positively influence outcomes. Key cognitive and behavioral abilities (e.g. self-efficacy beliefs and investing in resources for benefits in the longer-term) are considered essential.

- Behaviors and cognitions of health care professionals: Quality of care and outcomes for frail older patients are dependent on the professionals’ knowledge and understanding of the current situation of the patient. Moreover, behaviors such as collaboration and coordination among health care professionals are essential.

These cognitive and behavioral components of frail older persons and professionals are assumed to be important in fostering productive patient-professional interactions and improve well-being of frail older patients.

- Productive patient-professional interactions: Productive interactions are characterized by reciprocal interrelations between health care professionals and older people, and high levels of shared goals, shared knowledge, and mutual respect. These productive patient-professional interactions are at the core of patient-centered care and considered important in achieving the best possible patient outcomes.

Evaluation of the concepts: The concepts of the theoretical model can be evaluated by means of several validated questionnaires. Older persons’ experiences with integrated primary care can be measured using the short version of the Patient Assessment of Chronic Illness Care (PACIC-S) and professionals’ perceptions of integrated care can be assessed by means of the short version of the Assessment of Chronic Illness Care (ACIC-S). Cognitive and behavioral self-management abilities can be measured by means of the short version of the Self-Management Ability Scale (SMAS-S). The SMAS-S assesses six core abilities of self-management, e.g. self-efficacy beliefs and multifunctionality of resources. Cognitions and behaviors of health care professionals can be assessed using a Relational Coordination (RC) questionnaire. Relational coordination focusses on the quality of communication (e.g. frequent communication) and relationships (e.g. mutual respect) between health care professionals. The RC questionnaire can also be used to measure productive patient-professional interactions. The Social Production Function Instrument for the Level of Well-being (SPF-IL) can be used to assess well-being of frail older patients.

Discussion and conclusion: The implementation and evaluation of integrated care can be difficult as there are multiple elements and actors involved. To gain insight into the effectiveness and underlying mechanisms of these approaches, the proposed model provides an analytic method of understanding how elements of integrated care affect patient outcomes like well-being.

How to Cite: Vestjens L, Murray Cramm J, Petra Nieboer A. A model for the evaluation of integrated care approaches for frail older people. International Journal of Integrated Care. 2016;16(6):A141. DOI:
Published on 16 Dec 2016.


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