title: Comprehensive geriatric assessment, multifactorial interventions and nurse-led care coordination to prevent functional decline in community-dwelling older persons: protocol of a cluster randomized trial.
abstract: BACKGROUND
  Functional decline in community-dwelling older persons is associated with the loss of independence, the need for hospital and nursing-home care and premature death. The effectiveness of multifactorial interventions in preventing functional decline remains controversial. The aim of this study is to investigate whether functional decline in community-dwelling older persons can be delayed or prevented by a comprehensive geriatric assessment, multifactorial interventions and nurse-led care coordination.
  
  
  METHODS
  In a cluster randomized controlled trial, with the general practice as the unit of randomization, 1281 participants from 25 general practices will be enrolled in each condition to compare the intervention with usual care. The intervention will focus on older persons who are at increased risk for functional decline, identified by an Identification of Seniors at Risk Primary Care (ISAR-PC) score (≥ 2). These older persons will receive a comprehensive geriatric assessment, an individually tailored care and treatment plan, consisting of multifactorial, evidence-based interventions and subsequent nurse-led care coordination. The control group will receive 'care as usual' by the general practitioner (GP). The main outcome after 12 months is the level of physical functioning on the modified Katz-15 index score. The secondary outcomes are health-related quality of life, psychological and social functioning, healthcare utilization and institutionalization. Furthermore, a process evaluation and cost-effectiveness analysis will be performed.
  
  
  CONCLUSIONS
  This study will provide new knowledge regarding the effectiveness and feasibility of a comprehensive geriatric assessment, multifactorial interventions and nurse-led elderly care in general practice.
  
  
  BACKGROUND
  NTR2653 GRANT: Unrestricted grant 'The Netherlands Organisation for Health Research and development' no 313020201.
authors.affiliation: Department of General Practice, Academic Medical Center, Amsterdam, The Netherlands. j.j.suijker@amc.uva.nl
authors.forename: Jacqueline J
authors.initials: JJ
authors.lastname: Suijker
authors.forename: Bianca M
authors.initials: BM
authors.lastname: Buurman
authors.forename: Gerben
authors.initials: G
authors.lastname: ter Riet
authors.forename: Marjon
authors.initials: M
authors.lastname: van Rijn
authors.forename: Rob J
authors.initials: RJ
authors.lastname: de Haan
authors.forename: Sophia E
authors.initials: SE
authors.lastname: de Rooij
authors.forename: Eric P
authors.initials: EP
authors.lastname: Moll van Charante
mesh_terms: D000203:Activities of Daily Living; D000368:Aged; D000369:Aged, 80 and over; D016000:Cluster Analysis; D019317:Evidence-Based Medicine; D005260:Female; D015577:Geriatric Assessment; D006801:Humans; D008297:Male; D057184:Practice Patterns, Nurses'; D011320:Primary Health Care; D018570:Risk Assessment