Table 1 Interventions in individual studies

Junius-Walker et al., 2012 [20]

Intervention-tool: PrefCheck. The guide consists of the following:

(1) Disclosure of the patient’s rating of the importance of each health problem in tabular form

(2) A three-step guide to the exchange of health and treatment priorities in a patient-centred manner

(3) A sheet on which to document priority health problems

Intervention: 30-min GP training session in preparation for the priority setting consultations (use of an individual patient-related PrefCheck guide) by a research worker. A computer-aided geriatric assessment by a nurse after patient recruitment. Independent problem importance rating by GPs and patients, followed by a consultation using the PrefCheck. After 14 days, the second round of independent problem importance ratings, followed by a consultation using the PrefCheck.

Nature of desired change: To improve shared health priority setting between GP and patient.

Timing: One 30-min training session. Proximity to clinical decision-making is unclear. PrefCheck was given to the GP immediately before the consultation. 14-day follow-up period.

Comparison: Standard practice control group (consultation using the patient’s problem list without importance ratings and PrefCheck)

Wrede et al., 2013 [21]

Intervention: Same as Junius-Walker et al., 2012

Nature of desired change: To improve shared health priority setting between GP and patient.

Timing: 30-min GP training session in preparation for the priority setting consultations (use of an individual patient-related PrefCheck guide) by a research worker. A computer-aided geriatric assessment by a nurse, after patient recruitment. Independent problem importance rating by GPs and patients, followed by a consultation using the PrefCheck. Research on the first consultation. Follow-up consultations were not evaluated.

Comparison: Standard practice control group (consultation using the patient’s problem list without importance ratings)

Boult et al., 2008 [24]

Intervention: Guided Care [37]

A registered nurse completes an education programme and then uses a customised electronic health record (EHR) in working with 2 to 5 primary care physicians (PCP) to meet the complex needs of 50–60 older patients with multimorbidity. This Guided Care Nurse (GCN) has eight clinical activities:

1) Assessment: An initial assessment of the patient’s medical, functional, cognitive, affective, psychosocial, nutritional and environmental status during a visit at the patient’s home. The patient is asked to identify his or her highest priorities for optimising health and quality of life.

2) Planning: The EHR merges assessment data with evidence-based best practice recommendations to create a preliminary Care Guide. This preliminary Care Guide is adapted to reflect this individual patient by: 1) the GCN and the PCP, and 2) the GCN and the patient and caregiver. The final Care Guide summarises the patient’s status and plans to all professionals involved and is regularly updated by the GCN. A patient-friendly version (i.e. a lay version), called My Action Plan, is available in the patient’s home.

3) Chronic Disease Self-Management (CDSM): The patient’s self-efficacy in managing chronic conditions is promoted by referring him or her to a six-session CDSM course.

4) Monitoring: Monthly monitoring by telephone with reminders from the EHR to detect and address emerging problems. These problems are discussed with the PCP and appropriate action is taken.

5) Coaching: In conjunction with the monthly calls, the GCN uses motivational interviewing to reinforce the patient’s adherence to the Action Plan.

6) The GCN coordinates transitions between sites and care providers.

7) Educating and supporting caregivers. The GCN offers individual and group assistance to caregivers, consisting of initial assessment, a self-management course for caregivers, monthly support group meetings and ad hoc telephone consultations.

8) The GCN facilitates access to community resources.

Nature of desired change: Initiation of the Guided Care Model to improve several aspects of health care quality for elderly patients with multimorbidity.

Timing: Intervention duration 18 months, this article reports on results after 6 and 12 months.

Comparison: Standard practice control group (usual care instead of guided care)

Boyd et al., 2010 [23]

Intervention: Guided Care

Nature of desired change: Initiation of the Guided Care Model to improve several aspects of health care quality for elderly patients with multimorbidity.

Timing: Intervention reports on 18 months.

Comparison: Standard practice control group (usual care instead of guided care)

Wolff et al., 2010 [22]

Intervention: Guided Care Program for Family and Friends (GCPFF)

The GCN:

a) Makes an initial one-to-one assessment of the patient’s primary caregiver.

b) Educates the caregiver and refers him or her to community resources.

c) Offers ongoing ‘coaching’ to the caregiver.

d) Facilitates six 90-min caregiver workshops based on the chronic disease self-management philosophy and approach.

e) Facilitates one-hour-long unstructured monthly support group meetings.

Nature of desired change: Initiation of the Guided Care Model to improve several aspects of health care quality for elderly patients with multimorbidity from the patient’s and caregiver’s perspectives. Improvement of caregiver depression, strain and productivity and their perceptions of the quality of patient care.

Timing: Intervention reports on 18 months.

Comparison: Standard practice control group (usual care instead of guided care)

Bartels et al., 2014 [25]

Intervention: Helping Older People Experience Success (HOPES)

Combination of community living skills, social skills and healthy-living skills training with integrated preventive care coordinated by a nurse.

The intervention contains a psychosocial element, facilitated by rehabilitation specialists; it consists of weekly skills training in group sessions over 1 year, followed by monthly booster sessions. In addition, two monthly community trips were organized to practise skills.

The preventive element, HOPES Health Management, was facilitated by a nurse and consisted of monthly meetings to evaluate health care needs.

Collaborative goal-setting is part of the health management component. Another step in the health management component is the completion of advance directives.

Nature of desired change: Improvement of independent functioning and community tenure.

Timing: 3 years: 1 year intensive phase, 1 year maintenance phase and 1 year follow-up.

Comparison: Routine mental health services consisted of pharmacotherapy, case management or outreach by non-nurse clinicians, individual therapy, and access to rehabilitation services, such as groups and psychoeducation. Both intervention and control groups received these services.

Coventry et al., 2015 [26]

Intervention: Collaborative Care Model

Eight psychological therapy sessions delivered by case managers who are ‘psychological well-being practitioners’. In the first treatment session, the psychological well-being practitioner uses a structured patient-centred interview to gather information and then introduces the patient to the standardised treatment manual and workbook to help develop a main problem statement and personalised goals.

Two 10-min collaborative meetings (by telephone or in person) between the patient and the psychological well-being practitioner and a nurse from the patient’s general practice.

Psychological well-being practitioners also work collaboratively with the patient and the practice nurse to monitor medication use.

Use of established stepped care protocols.

Psychological well-being practitioners received 5 days of training about the COINCIDE collaborative care model. Practice nurses followed a half-day workshop. Psychological well-being practitioners attended a weekly supervision session.

Nature of desired change: Improvement of care access and quality.

Timing: Eight brief face-to-face psychological therapy sessions (i.e. 30–45 min) within 3 months. Two collaborative meetings after sessions 2 and 8. Reports on results measured after 4 months.

Comparison: Care as usual delivered by the general practitioner.

Blom et al., 2016 [27]

Intervention: The Integrated Systematic Care for Older PEople

The GPs and nurses carrying out the intervention practices were trained in the delivery of proactive integrated care (e.g. in designing, conducting and adjusting a care plan). The GP or the practice nurse (under the supervision of the GP) created an integrated care, action and evaluation plan for participants with complex problems. Other care professionals were involved where needed (multidisciplinary consultation).

The participant’s wishes and expectations about goals to be achieved were explored together with the informal caregiver(s). These priorities and goals were used as a starting point for making a care plan.

Nature of desired change: The development of a care plan focusing on functioning for people with complex problems (i.e. a combination of somatic, functional, mental and social health problems).

Timing: Two 3-h GP/practice nurse training sessions. Care plans for the first 10 patients per participating GP were made over a two- to three-month period. Follow-up period of 1 year.

Comparison: Usual care. Participants receiving usual care were not included in the final analysis.