Table 2.
Prevention and Reactivation Care Program Interventions
| Intervention | PReCaP Core Staff |
|---|---|
| Hospital | |
| Identification of patient at risk within 48 h after admission | Research nurse |
| Assessment of risk factors for functional decline | Research nurse |
| Consult with patient and relatives to discuss vulnerability and risk factors | Casemanager or geriatric nurse |
| Biweekly Multidisciplinary Team Meeting: | Geriatrician |
| • Analysis of the function diagnosis in relation to the medical diagnosis | Geriatric nurse |
| • Design GAS care plan including advice for additional treatment aimed at functional preservation | Nurse practitioner |
| Social worker | |
| Transfer nurse | |
| Casemanager | |
| Geriatric consultation | Geriatrician |
| Geriatric nurse | |
| Casemanager | |
| Transfer nurse | |
| Interdisciplinary consultation, e.g. psychiatrist, psychologist, physiotherapist, occupational therapist, dietician, behavioral consultant | Geriatrician |
| Casemanager | |
| Support and provide treatment to informal caregiver (optional) | Social worker |
| Review prognosis and discharge destination (in some cases register patient at hospital replacement care facility) | Psychologist |
| Geriatrician | |
| Geriatric nurse | |
| Nurse practitioner | |
| Social worker | |
| Transfer nurse | |
| Casemanager | |
| Weekly telephone consultation informal caregiver | Casemanager |
| Hand out flyer 'PReCaP Recovery Team' to patient | Casemanager |
| Exit interview with patient and informal caregiver | Transfer nurse |
| Hand out flyer 'Prevention and Reactivation Centre' to patient (if transfer to PRC) | Transfer nurse |
| Handover GAS care plan to physician hospital replacement care facility | Casemanager or geriatrician |
| Home visit and support after hospital discharge until six months after hospital admission, including optional therapy | Casemanager |
| Prevention and Reactivation Centre | |
| Admission to PRC (including GAS care plan/medical handover) | Nurse practitioner |
| Review GAS care plan | Nursing home physician or nurse practitioner |
| Physical examination | Nursing home physician |
| Intake patient/informal caregiver | Nurse |
| Weekly Multidisciplinary Team Meeting: | Nursing home physician (coordinator) |
| • First MTM after one week admission PRC | Nurse practitioner Casemanager Psychiatrist (in consultation) |
| • Review progress and adjust GAS care plan | Social worker (in consultation) |
| • Casemanager home care attends MTM in week 9 | Clinical geriatrician (in consultation) |
| Introduction and intake patient | Nurse |
| Treatment according to GAS care plan | Consulted disciplines |
| If needed additional treatment by PReCaP recovery team and other disciplines if indicated, e.g. behavioral therapist, dietician, music therapist, dance therapist, visual arts therapist | Casemanager |
| Hand over diary to patient (incl. therapy appointments and treatment information) | Nurse |
| Support with activities according to diary | Nurse |
| Specialized nursing home care within the socio-therapeutic environment, e.g. psychologist, physiotherapist (3 times a week), occupational therapist, speech therapist, dietician, behavioral therapist, music therapist, dance therapist, visual arts therapist, social worker | Casemanager |
| Review medication use | Nursing home physician |
| Support informal caregiver | Psychologist Casemanager |
| Assessment of Motor and Process Skills | Occupational therapist |
| Before discharge home visit (in week 9) | Occupational therapist |
| If needed consultation external expertise, e.g. ophthalmologist, otolaryngologist, (orthopedic) surgeon, psychiatrist, neurologist, dermatologist, rehabilitation specialist | Nursing home physician |
| If needed short term admission to psychiatric hospital or re-admission to hospital | Nursing home physician |
| Hand out flyer 'PReCaP route after discharge' | Casemanager |
| At discharge: write-up report GAS care plan, including advice additional treatment aimed at function preservation in the home environment | Nursing home physician (coordinator) |
| Nurse practitioner Casemanager Psychiatrist (in consultation) | |
| Social worker (in consultation) | |
| Clinical geriatrician (in consultation) | |
| At discharge: write-up discharge letter | Nursing home physician Nurse practitioner |
| At discharge: write-up handover | Involved disciplines |
| At discharge: handover care plan to general practitioner | Casemanager |
| If home care after PRC discharge: intake casemanager homecare in the presence of casemanager PReCaP ('warm handover') | Casemanager |