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Table 1 Overview of interventions implemented in intervention (FFF approach) and control (usual primary care) GP practices

From: An integrated primary care approach for frail community-dwelling older persons: a step forward in improving the quality of care

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  
  1. COPD Chronic Obstructive Pulmonary Disease, FFF Finding and Follow-up of Frail older persons, GP general practitioner, ICT information and communication technology