Personalized Primary Care for Older People: An evaluation of a multicomponent nurse-led care program: an evaluation of a multicomponent nurse-led care program

Providing optimal care for the increasing number of frail older people with complex care needs is a major challenge in primary care. The current approach is reactive and does not meet the needs of older patients, resulting in unnecessary loss of daily functioning, suboptimal quality of life and high health care expenditures. In the Utrecht Proactive Frailty Intervention Trial (U-PROFIT, in Dutch:’ Om U’), we designed and evaluated a strategy for proactive patient-centred primary care of frail older people. The strategy consists of the Utrecht Periodic Risk Identification and Monitoring (U-PRIM) system, a frailty screening intervention based on administrative patient data, and U-CARE, a nurse-led personalised care intervention comprising frailty screening, comprehensive geriatric assessment and evidence-based care planning. In this thesis, we aimed to describe the development of U-CARE in detail and evaluated the effectiveness on the preservation of physical functioning of frail older people. Both interventions led to better preservation of physical functioning compared to the control group. More highly educated older people had additional benefits from U-CARE, indicating that the effect is dependent on individual patient characteristics. The U-CARE program was highly appreciated by the nurses and GPs and considered the program valuable for the implementation and coordination of personalized proactive care. They perceived that older patients were more ‘visible’ in the general practice. Interviews with a subsample of older persons showed that personalized nurse-led care was well appreciated when the relationship, the timing, and nurses’ roles were tailored to the patient’s needs. Secondary analysis of our trial data, we showed that older people who have a relatively low number of chronic medications, a higher education level, a higher self-reported quality of life and who are not using a walking aid are most likely to benefit from personalized nurse-led care