Table 1 Activities related to the FFF integrated primary care approach
FFF related activities | Explanation | Disciplines involved | Mean time per patient |
|---|---|---|---|
Selection of patients | Selecting patients that are eligible for proactive frailty screening | GP or practice nurse | 5Â min |
Proactive frailty screening | Home visit for administering the Tilburg Frailty Indicator (TFI) to assess frailty. Consultation with the patient and reporting needs and problems based on the SFSPC-model, i.e., model for reporting on Somatic, Functional, Social, Psychological, and Communicative indications | Practice nurse, geriatric nurse, or homecare nurse | 90Â min |
Feedback information | Feedback information about the screening (e.g., TFI score) and problem analysis (SFSPC-model) to the GP and elderly care physician. First draft of individualized care plan for the patient | Practice nurse, geriatric nurse, or homecare nurse | 100Â min |
Multidisciplinary consultation | Discussing the older patient in multidisciplinary consultation in the GP practice. Discussion of screening, problems listed according to SFSPC-model, possible (self-management) interventions, and involvement of (healthcare) professionals | In general GP Practice nurse Homecare nurse Elderly care physician Geriatric nurse Frequently involved Physiotherapist, occupational therapist and/or social worker | On average patients are discussed once or twice per year for 15Â min |
Individualized care plan | Definitive version of the individualized care plan is established, including (self-management) interventions discussed in multidisciplinary consultation | Practice nurse, geriatric nurse, or homecare nurse | 10Â min |
Medication review | Older persons’ medication use is examined in a medication review | GP, pharmacist, or elderly care physician | 10 min |
Multidisciplinary follow-up | Individual follow-up of patients by a multidisciplinary team of (healthcare) professionals. A case manager is responsible for coordination and evaluation of the follow-up. An elderly care physician and geriatric nurse can provide geriatric expertise | Involvement of (healthcare) professionals based on the needs and wishes of the patient and can include, but are not limited to, practice nurses, physiotherapists, medical specialists, social workers, and so on | 4 to 10Â h |