Table 1.
Overview of interventions implemented in intervention (FFF approach) and control (usual primary care) GP practices
| CCM dimension | Intervention | Intervention practices (n = 11) | Control practices (n = 4) | ||
|---|---|---|---|---|---|
| n | % | n | % | ||
| Healthcare organization | Integrated financing | 2 | 18 | 0 | 0 |
| Healthcare organization | Specific policies and subsidies for immigrant population | 0 | 0 | 0 | 0 |
| Healthcare organization | Sustainable financing agreements with health insurers | 4 | 36 | 0 | 0 |
| Healthcare organization | Financing Geriatric Care Module | 10 | 91 | 0 | 0 |
| Community linkages | Multidisciplinary and transmural collaboration | 3 | 27 | 1 | 25 |
| Community linkages | Shared structural approach between hospital and primary care | 3 | 27 | 2 | 50 |
| Community linkages | Setting up transmural care pathways/care protocols | 3 | 27 | 2 | 50 |
| Community linkages | Referral and information exchange arrangements between primary and hospital care | 5 | 45 | 3 | 75 |
| Community linkages | Cooperation with external community partners | 11 | 100 | 4 | 100 |
| Community linkages | Joint treatment plan between primary and hospital care | 3 | 27 | 1 | 25 |
| Community linkages | Involvement of patient groups and panels in care design | 0 | 0 | 0 | 0 |
| Community linkages | Communication platform between stakeholders about patients | 2 | 18 | 0 | 0 |
| Community linkages | Role model in the area | 5 | 45 | 0 | 0 |
| Community linkages | Regional training course | 9 | 82 | 2 | 50 |
| Community linkages | Regional collaboration for the care of frail older persons | 8 | 73 | 1 | 25 |
| Community linkages | Family participation | 11 | 100 | 4 | 100 |
| Community linkages | Geriatric network | 1 | 9 | 0 | 0 |
| Self-management support | Promotion of disease-specific information | 11 | 100 | 3 | 75 |
| Self-management support | Individual care plan | 10 | 91 | 2 | 50 |
| Self-management support | Diagnosis and treatment of mental health issues | 10 | 91 | 3 | 75 |
| Self-management support | Lifestyle intervention (e.g., physical activity, diet, smoking) | 8 | 73 | 2 | 50 |
| Self-management support | Support of self-management (e.g., Internet) | 5 | 45 | 3 | 75 |
| Self-management support | Telemonitoring | 1 | 9 | 0 | 0 |
| Self-management support | Personal coaching | 10 | 91 | 4 | 100 |
| Self-management support | Motivational interviewing | 6 | 55 | 1 | 25 |
| Self-management support | Reflection interviews | 0 | 0 | 0 | 0 |
| Self-management support | Informational meetings | 2 | 18 | 0 | 0 |
| Self-management support | Group session for patient and family | 1 | 9 | 0 | 0 |
| Self-management support | Cognitive behavioral therapy | 3 | 27 | 2 | 50 |
| Decision support | Care standards/clinical guidelines | 11 | 100 | 4 | 100 |
| Decision support | Uniform treatment protocol in outpatient and inpatient care | 2 | 18 | 1 | 25 |
| Decision support | Training and independence of practice nurses | 9 | 82 | 3 | 75 |
| Decision support | Professional education and training for care providers | 9 | 82 | 3 | 75 |
| Decision support | Audit and feedback | 4 | 36 | 1 | 25 |
| Decision support | Use of care protocols for immigrants | 0 | 0 | 0 | 0 |
| Decision support | Structural participation in knowledge exchange/best practices | 3 | 27 | 0 | 0 |
| Decision support | Quality of life questionnaire | 7 | 64 | 1 | 25 |
| Decision support | Automatic measurement of process/outcome indicators | 3 | 27 | 1 | 25 |
| Decision support | Evaluation of healthcare via focus groups with patients | 0 | 0 | 1 | 25 |
| Decision support | Measurement of patient satisfaction | 5 | 45 | 2 | 50 |
| Decision support | Guideline Finding and Follow-up of Frail older persons | 10 | 91 | 0 | 0 |
| Decision support | Guideline Geriatric Care Module | 11 | 100 | 0 | 0 |
| Delivery system design | Delegation of care from GP to (practice) nurse | 9 | 82 | 2 | 50 |
| Delivery system design | Substitution of inpatient with outpatient care | 8 | 73 | 2 | 50 |
| Delivery system design | Intensifying collaboration with ongoing projects | 6 | 55 | 2 | 50 |
| Delivery system design | Systematic follow-up of patients | 9 | 82 | 2 | 50 |
| Delivery system design | Specific plan for immigrant population | 0 | 0 | 0 | 0 |
| Delivery system design | Joint Medical Consult | 1 | 9 | 0 | 0 |
| Delivery system design | Meetings of professionals from different disciplines to exchange information | 11 | 100 | 2 | 50 |
| Delivery system design | Joint consultations | 0 | 0 | 0 | 0 |
| Delivery system design | Proactive monitoring of high-risk patients | 11 | 100 | 1 | 25 |
| Delivery system design | Board of clients | 0 | 0 | 0 | 0 |
| Delivery system design | Bottleneck analysis between professionals and patients | 0 | 0 | 0 | 0 |
| Delivery system design | Stepped care method | 4 | 36 | 0 | 0 |
| Delivery system design | Expansion of chain of care to the secondary care setting | 3 | 27 | 1 | 25 |
| Delivery system design | Proactive screening for frailty | 11 | 100 | 0 | 0 |
| Delivery system design | Medication review | 11 | 100 | 3 | 75 |
| Clinical information systems | Electronic patient records system with patient portal | 3 | 27 | 1 | 25 |
| Clinical information systems | GP information system | 11 | 100 | 4 | 100 |
| Clinical information systems | Chain information system (e.g., COPD, diabetes) | 11 | 100 | 4 | 100 |
| Clinical information systems | Use of ICT for internal and/or regional benchmarking relevant for frail older patients | 4 | 36 | 0 | 0 |
| Clinical information systems | Systematic registration by every caregiver | 9 | 82 | 3 | 75 |
| Clinical information systems | Creation of a safe environment for data exchange | 8 | 73 | 4 | 100 |
| Clinical information systems | Exchange of information among care disciplines | 8 | 73 | 3 | 75 |
| Average number of interventions implemented | 33 | 23 | |||
COPD Chronic Obstructive Pulmonary Disease, FFF Finding and Follow-up of Frail older persons, GP general practitioner, ICT information and communication technology