Abstract
BackgroundHospital related functional decline in older patients is an underestimated problem. Thirty-five procent of 70-year old patients experience functional decline during hospital admission in comparison with pre-illness baseline. This percentage increases considerably with age.Methods/designTo address this issue, the Vlietland Ziekenhuis in The Netherlands has implemented an innovative program (PReCaP), aimed at reducing hospital related functional decline among elderly patients by offering interventions that are multidisciplinary, integrated and goal-oriented at the physical, social, and psychological domains of functional decline.DiscussionThis paper presents a detailed description of the intervention, which incorporates five distinctive elements: (1) Early identification of elderly patients with a high risk of functional decline, and if necessary followed by the start of the reactivation treatment within 48 h after hospital admission; (2) Intensive follow-up treatment for a selected patient group at the Prevention and Reactivation Centre (PRC); (3) Availability of multidisciplinary geriatric expertise; (4) Provision of support and consultation of relevant professionals to informal caregivers; (5) Intensive follow-up throughout the entire chain of care by a casemanager with geriatric expertise. Outcome and process evaluations are ongoing and results will be published in a series of future papers.Trial registrationThe Netherlands National Trial Register: NTR2317
Highlights
This paper presents a detailed description of the intervention, which incorporates five distinctive elements: (1) Early identification of elderly patients with a high risk of functional decline, and if necessary followed by the start of the reactivation treatment within 48 h after hospital admission; (2) Intensive follow-up treatment for a selected patient group at the Prevention and Reactivation Centre (PRC); (3) Availability of multidisciplinary geriatric expertise; (4) Provision of support and consultation of relevant professionals to informal caregivers; (5) Intensive follow-up throughout the entire chain of care by a casemanager with geriatric expertise
There is a paucity of detailed descriptions of geriatric interventions in the international literature. This paper addresses this issue by presenting an outline of the Prevention and Reactivation Care Program (PReCaP) including community involvement; the roles and responsibilities of core staff; the setting and administrative structure; the care process - including identification and screening procedure, key interventions, use of the standardized Goal Attainment Scaling (GAS) method, follow-up treatment at the Prevention and Reactivation Centre, multidisciplinary approach, case management, provision of support to informal caregivers, quality assurance measures -; and the expected outcomes and benefits
The PReCaP includes the following distinctive elements: (1) Early identification of elderly patients with a high risk of functional decline, and if necessary followed by the start of the reactivation treatment within 48 h after hospital admission; (2) Intensive follow-up treatment, for a maximum period of three months, of a selected patient group at the Prevention and Reactivation Centre (PRC) following referral from the multidisciplinary team
Summary
Introduction and intake patientTreatment according to GAS care planConsulted disciplinesIf needed additional treatment by PReCaP recovery team and other disciplines if indicated, e.g. behavioral therapist, dietician, music therapist, dance therapist, visual arts therapistHand over diary to patient (incl. therapy appointments and treatment information)Support with activities according to diarySpecialized nursing home care within the socio-therapeutic environment, e.g. psychologist, Casemanager physiotherapist (3 times a week), occupational therapist, speech therapist, dietician, behavioral therapist, music therapist, dance therapist, visual arts therapist, social workerAt discharge: write-up discharge letterAt discharge: write-up handover At discharge: handover care plan to general practitioner If home care after PRC discharge: intake casemanager homecare in the presence of casemanager PReCaP (’warm handover’)Nursing home physician Psychologist Casemanager Occupational therapist Occupational therapist Nursing home physicianNursing home physician Casemanager Nursing home physician (coordinator)Nurse practitioner Casemanager Psychiatrist (in consultation) Social worker (in consultation) Clinical geriatrician (in consultation) Nursing home physician Nurse practitioner Involved disciplines Casemanager Casemanager. If needed additional treatment by PReCaP recovery team and other disciplines if indicated, e.g. behavioral therapist, dietician, music therapist, dance therapist, visual arts therapist. Specialized nursing home care within the socio-therapeutic environment, e.g. psychologist, Casemanager physiotherapist (3 times a week), occupational therapist, speech therapist, dietician, behavioral therapist, music therapist, dance therapist, visual arts therapist, social worker. Thirty-five procent of 70-year old patients experience functional decline during hospital admission in comparison with pre-illness baseline. Thirty-five percent of 70-year old patients experience functional decline during hospital admission in comparison with pre-illness baseline. This percentage increases to 50% for 85-year old patients [1].
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