Extrait

Background and study aims By 2050, the number of Europeans over 65 will double and the number of over 75 will almost triple, causing a steep increase in demand for care. Care is currently characterised by a professional approach, where health and social care are isolated from each other. Urban Health Centres Europe (UHCE) is a European research project which started in January 2014. It promotes integrated health and social care, early detection of frailty, management of polypharmacy (the use of four or more medications), the prevention of falls and management of loneliness for active and healthy ageing in European cities. The aim of this study is to compare this approach with the usual care for community-dwelling older citizens aged 75 and older. Who can participate? People aged 75+ who are living independently What does the study involve? The intervention and control sites (GP practices or primary care centers) are located in different areas of the city. Participants are allocated to the intervention and control groups based on their location (whether they live in the area of the control or intervention site). In Pallini participants are randomly allocated into the intervention and control groups. The control group receives usual care, and no care plan is made or carried out based on the assessment. The intervention group receives the UHCE approach, which starts with an assessment of frailty and fall risks, medication risks and loneliness in order to identify priorities for prevention and care. The results of the assessments are discussed with the older person, a person in charge of care coordination (nurse practitioner or other) and a physician. A decision on a (preventive) care plan is made, which can include frailty action (based on the judgement of a physician), fall prevention actions (including exercise groups, home hazard identification or other actions based on the judgement of a physician), actions addressing medication risk and polypharmacy (including appropriate prescribing and adherence action or other actions based on the judgement of a physician) and actions addressing loneliness (including support groups, social activities, or other actions based on the judgement of a physician). The care coordinator (usually a nurse or a trained physician assistant) coordinates and monitors the progress of the care plan under the supervision of the physician. Follow-up appointments are scheduled if needed. The care coordinator monitors the compliance and success of care. Healthy lifestyle, fall risk, medication risk, loneliness, frailty, hand-grip strength, mid-upper arm circumference, level of independence and quality of life are measured at the start of the study and after 12 months. What are the possible benefits and risks of participating? Participants benefit from receiving a health assessment and appropriate follow-up care such as exercise groups or social activities, based on their wishes and in consultation with their healthcare provider. There are no risks associated with participating, the assessment takes about 1 hour, and follow-up care is advised by the participant's healthcare provider and is always in agreement with the participant. Where is the study run from? 1. Zorg op Noord (Netherlands) 2. Polibienestar Research Institute - Universitat de València (Spain) 3. Municipality of Pallini (Greece) 4. University of Manchester (UK) 5. University of Rijeka, Faculty of Medicine (Croatia) When is the study starting and how long is it expected to run for? January 2014 to December 2017 Who is funding the study? The Third EU Health Programme Who is the main contact? 1. Prof. Hein Raat (scientific) ([email protected]) 2. Ms Carmen Franse (public)

Critère d'inclusion

• Healthy lifestyles, fall risk, medication risk and loneliness level, frailty, level of independence, and health-related quality of life

Liens

• isrctn