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Table 1 Overview of outcomes, baseline measurements and follow-up measurements

From: Implementing the chronic care model for frail older adults in the Netherlands: study protocol of ACT (frail older adults: care in transition)

Older adults Instrument Baseline 6 Months 12 Months 18 Months 24 Months
Patient outcomes 1. Quality of Life SF-12 [26] x x x x x
  2. Health-related Quality of Life EuroQol (EQ-5D) [27] x x x x x
  3. Independence in ADL Katz ADL index [28] x x x x x
  4. Psychological Wellbeing RAND-36 subscale [29] x x x x x
  5. Social Functioning 1 item on RAND-36 scale x x x x x
  6. Self-reported Health 2 items on RAND-36 scale x x x x x
  7. Acute Hospital Admissions 1 item of our data set and Cost Dairies x x x x x
Quality of Care 8. Care Needs CANE [30] x   x   x
Process Outcomes: Achieved transition 9. Patient-reported Client-centred Care CCCQ [31] x x x x x
  10. Coordination of Care from the patient’s perspective 2 items on QUOTE [32] x x x x x
Informal Caregivers Instrument Baseline 6 Months 12 Months 18 Months 24 Months
Carer outcomes 12. Quality of life SF-12 x x x x x
  13. Self-rated Burden of Care CarerQol [33] x x x x x
Older adults and informal caregivers Instrument Baseline 6 Months 12 Months 18 Months 24 Months
Costs Direct and Indirect Costs Cost diaries
  1. SF-12 Short Form-12 questionnaire; EuroQol (EQ-5D) measures of 5 dimensions of health-related quality of life; Katz ADL Katz Activities of Daily Living; RAND-36 measure of health-related quality of life; CANE Camberwell assessment of needs in the elderly; Arm 1-4 allocation arm number 1–4; CCCQ Client-centred Care Questionnaire; QUOTE QUality Of care Through the patient’s Eyes; CarerQol care-related quality of life of informal caregivers