Formulation of and adherence to a care plan for potentially frail community-dwelling older people by practice nurses in the Netherlands

Abstract

Background: In the Netherlands, practice nurses within general practices increasingly deliver proactive care to older people. As part of a home visitation programme, they assess older people's health status during a home visit, followed by formulating a care plan and monitoring follow-up care. Insight into the latter two steps is limited, whereas previous research shows signs of inadequate follow-up, threatening the achievement of optimal patient outcomes. The objectives of the current study are to investigate practice nurses' actions and views regarding (1) the formulation of a care plan for potentially frail community-dwelling older people following a comprehensive geriatric assessment during a home visit and (2) their adherence to the care plan and monitoring during follow-up of older people in whom health and/or well-being problems have been detected. Methods:A cross-sectional mixed-model study was conducted. Results of the comprehensive geriatric assessment were compared to the care plans to reveal the percentage of problems included. Semi-structured interviews were performed with 12 practice nurses who visited older people at home. Per practice nurse, care plans of 10 older people (total n = 120) were purposefully selected and discussed to identify reasons for not registering problems in the care plan and to determine whether and how problems were monitored.Results: Of the problems identified through comprehensive geriatric assessment, 27.8% (n = 275) were included in a care plan of which 62.9% (n = 173) were addressed using follow-up actions. Patient-related and problem-specific factors influenced the formulation of care plans. Insufficient time challenged practice nurses in monitoring older people over time. Conclusions:The formulation of care plans and monitoring older people over time offers room for improvement. Once problems are included into the plans, practice nurses mostly adhere to the care plans.

Risk Instrument for Screening in the Community (RISC): Cross Cultural Perspectives

“…Population wide screening and early identification of older adults, at risk of frailty and adverse outcomes, will enable triage and targeted priorities of social and health services and supports by HCPs in an effort to prevent or postpone these adverse outcomes. Internationally, nurses in the community use a variety of methods and assessments to identify frail older people in an attempt to identify the level of risk to prioritise anticipatory care (Ballard et al, 2013;Stijnen et al, 2014;Yoshioka-Maeda et al, 2006). O'Caoimh et al (2015) developed and validated a short screening tool, The Risk Instrument for Screening in the Community (RISC, Appendix 1), with public health nurses, for use in community dwelling older adults to screen for risk of frailty and AO.…”