Enhanced Primary Care for Elderly

Study Overview
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Brief Summary
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The present health care situation for the elderly in many countries is insufficient and not designed according to the health care needs of the aged population. In a pragmatic multicenter primary care setting (n= 1600), the investigators use an evidence based prediction model to find elderly (75+) with high risk for complex medical care or hospitalization and apply a differentiated and directed medical and social care to this risk group, in comparison to usual care. The intervention will include all the latest evidence based tools in the care of elderly (multi-professional team, social support, medical care home-visits, telephone support, general practitioner visits, etc). The project has high potential impact on the development of future care of elderly. In addition to the intervention study, several academic sub-studies focusing on patient's perspective, professional roles, equality, implementation and governance management of health care will be performed.

Detailed Description
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The current project is a multidisciplinary research project covering several aspects of a shift in elderly care, with outcome measures not only related to primary medical or functional measures. The analyses will widen the view to overall societal costs and effects of changes in key institutions of social security as well as to hidden mechanisms in the governance system of care and health care of elderly. The primary aim of the present study is to investigate the extent to which a differentiated (personalized) and targeted primary care intervention provided to a statistically predicted risk population of elderly, results in care that is more effective and of higher quality than that of a control group receiving standard care. In a pragmatic multicenter primary care setting (n= 1600), an evidence based prediction model to find elderly (75+) with high risk for complex medical care or hospitalization is used followed by a differentiated and directed medical and social care to this risk group, in comparison to usual care. The intervention will include all the latest evidence based tools in the care of elderly (multi-professional team, social support, medical care home-visits, telephone support, general practitioner visits, etc). The investigators also aim to study the care model in a broader sense; experiences of the elderly, their social networks and diversity. Finally, the project will also investigate how the health care system, from specific health care professionals (primary care nurses, doctors, para-medical staff) to management levels and politicians influence the implementation of the present and future care models. One specific subproject focuses on the mechanisms behind the inability of steak holders/politicians and top administrative executives to find efficient governance principals for elderly care and health care, despite already available knowledge sources.

Official Title
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Enhanced Primary Care for Elderly: A Multicenter Pragmatic Clinical Trial Where Older People With Great Needs Are Predicted and Given Personalized Primary Care

Conditions
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Frail Elderly Syndrome

Intervention / Treatment
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* Other: Multi-disciplinary and personalized primary care


Participation Criteria
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Eligibility Criteria
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Inclusion Criteria: Age 75 years and older living in county of Östergötland Exclusion Criteria: No exclusion criteria

Ages Eligible for Study
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Minimum Age: 75 Years
Maximum Age: 110 Years

Sexes Eligible for Study
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All

Study Plan
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How is the study designed?
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Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Predicted and personalized primary care<br>Elderly 75 years of age and older in primary care with high risk of being fragile and future risk of needing hospital care that receives personalized primary care | Other: Multi-disciplinary and personalized primary care<br>* Team-based primary care where nurse, GP, social-worker, physiotherapist, occupational therapist evaluate and give treatment<br>|
| Predicted but with treatment as usual<br>Elderly 75 years of age and older in primary care with high risk of being fragile and future risk of needing hospital care that receives treatment as usual | |

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Hospital care days | The number of days in hospital | January 1st 2018 - December 31st 2019 | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Hospital care occasions | Number of occasions in hospital care | January 1st 2018 - December 31st 2019 | 
| Health related quality of life | Measured as EQ-5D scores | January 1st 2018 - December 31st 2019 | 
| Costs for health care | The total costs for health care measured in USD | January 1st 2018 - December 31st 2019 | 
| Mortality | Number of deaths during the study period | January 1st 2018 - December 31st 2019 | 

 Terms related to the study
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Keywords Provided by Centre Hospitalier Valida
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Elderly, Frail, Primary care