title: Implementing the chronic care model for frail older adults in the Netherlands: study protocol of ACT (frail older adults: care in transition).
abstract: BACKGROUND
  Care for older adults is facing a number of challenges: health problems are not consistently identified at a timely stage, older adults report a lack of autonomy in their care process, and care systems are often confronted with the need for better coordination between health care professionals. We aim to address these challenges by introducing the geriatric care model, based on the chronic care model, and to evaluate its effects on the quality of life of community-dwelling frail older adults.
  
  
  METHODS
  In a 2-year stepped-wedge cluster randomised clinical trial with 6-monthly measurements, the chronic care model will be compared with usual care. The trial will be carried out among 35 primary care practices in two regions in the Netherlands. Per region, practices will be randomly allocated to four allocation arms designating the starting point of the intervention.
  
  
  METHODS
  1200 community-dwelling older adults aged 65 or over and their primary informal caregivers. Primary care physicians will identify frail individuals based on a composite definition of frailty and a polypharmacy criterion. Final inclusion criterion: scoring 3 or more on a disability case-finding tool.
  
  
  METHODS
  Every 6 months patients will receive a geriatric in-home assessment by a practice nurse, followed by a tailored care plan. Expert teams will manage and train practice nurses. Patients with complex care needs will be reviewed in interdisciplinary consultations.
  
  
  RESULTS
  We will perform an effect evaluation, an economic evaluation, and a process evaluation. Primary outcome is quality of life as measured with the Short Form-12 questionnaire. Effect analyses will be based on the "intention-to-treat" principle, using multilevel regression analysis. Cost measurements will be administered continually during the study period. A cost-effectiveness analysis and cost-utility analysis will be conducted comparing mean total costs to functional status, care needs and QALYs. We will investigate the level of implementation, barriers and facilitators to successful implementation and the extent to which the intervention manages to achieve the transition necessary to overcome challenges in elderly care.
  
  
  CONCLUSIONS
  This is one of the first studies assessing the effectiveness, cost-effectiveness and implementation process of the chronic care model for frail community-dwelling older adults.
  
  
  BACKGROUND
  The Netherlands National Trial Register NTR2160.
authors.affiliation: Department of General Practice and Elderly Care Medicine/EMGO + Institute for Health and Care Research, VU University medical center, Amsterdam, the Netherlands. m.muntinga@vumc.nl.
authors.forename: Maaike E
authors.initials: ME
authors.lastname: Muntinga
authors.forename: Emiel O
authors.initials: EO
authors.lastname: Hoogendijk
authors.forename: Karen M
authors.initials: KM
authors.lastname: van Leeuwen
authors.forename: Hein P J
authors.initials: HP
authors.lastname: van Hout
authors.forename: Jos W R
authors.initials: JW
authors.lastname: Twisk
authors.forename: Henriette E
authors.initials: HE
authors.lastname: van der Horst
authors.forename: Giel
authors.initials: G
authors.lastname: Nijpels
authors.forename: Aaltje P D
authors.initials: AP
authors.lastname: Jansen
mesh_terms: D000368:Aged; D003362:Cost-Benefit Analysis; D016330:Frail Elderly; D015577:Geriatric Assessment; D006299:Health Services for the Aged / Q000191:economics / Q000458:organization & administration*; D006801:Humans; D017146:Models, Organizational; D009426:Netherlands; D010348:Patient Care Team / Q000458:organization & administration; D018579:Patient Selection; D011320:Primary Health Care / Q000458:organization & administration; D016730:Program Development; D015397:Program Evaluation; D011788:Quality of Life