Outcome | Concept | Methods |
---|---|---|
Level of implementation | Fidelity | ·Semi-structured interviews* with geriatric team members, nurses, primary care physicians ·Focus groups* with practice nurses ·Tailored care plans, time registration by practice nurses, registrations by expert geriatric teams, minutes of team meetings and training sessions |
Dose delivered (completeness) | ·Tailored care plans Total number of care plans delivered to clients during the intervention ·Tailored care plans (sample) Average number of observations (RAI outcomes, nurses’ own observations) per care plan Average number of actions formulated per care plan Average number of care professionals involved in actions listed ·Time registrations by practice nurses Average amount of nurse’s working hours spent delivering intervention components (e.g. In-home assessments and care plan evaluation with clients, consultations with primary care physician, multidisciplinary consultations) ·Registrations by expert geriatric teams Number of multidisciplinary consultations organized | |
Dose received (exposure, satisfaction) | ·Minutes of team meetings, registrations by expert geriatric teams Number of training and coaching sessions and frequency of nurse’s attendance at these sessions Number of team meetings and frequency of nurse’s attendance at these meetings ·Semi-structured interviews* with geriatric team members, nurses, primary care physicians ·Focus groups* with practice nurses, local stakeholders | |
Barriers and facilitators to implementation | Barriers on cultural, operational and structural levels | ·Semi-structured interviews* with older adults, geriatric team members, nurses, primary care physicians ·Focus groups * with practice nurses, stakeholders |
Extent to which transition is achieved | Client autonomy | ·Semi-structured interviews * with older adults ·CCCQ questionnaire ** |
Coordination of care from the perspective of health professionals and patients | ·Semi-structured interviews * with geriatric team members, nurses, primary care physicians, older adults ·Focus groups * with practice nurses ·2 Items on QUOTE questionnaire ** | |
Learning experiences of professionals | Timely identification of health problems and care needs | ·Tailored care plans Percentage of total number of RAI outcomes and nurses’ own registrations previously unknown to heath care professionals |
·Semi-structured interviews * with geriatric team members, nurses, primary care physicians ·Focus groups * with practice nurses, stakeholders |