Table 2 Prevention and Reactivation Care Program Interventions
Intervention | PReCaP Core Staff |
|---|---|
Hospital | Â |
Identification of patient at risk within 48 h after admission | Research nurse |
Assessment of risk factors for functional decline | Research nurse |
Consult with patient and relatives to discuss vulnerability and risk factors | Casemanager or geriatric nurse |
Biweekly Multidisciplinary Team Meeting: | Geriatrician |
• Analysis of the function diagnosis in relation to the medical diagnosis | Geriatric nurse |
• Design GAS care plan including advice for additional treatment aimed at functional preservation | Nurse practitioner |
| Â | Social worker |
| Â | Transfer nurse |
| Â | Casemanager |
Geriatric consultation | Geriatrician |
| Â | Geriatric nurse |
| Â | Casemanager |
| Â | Transfer nurse |
Interdisciplinary consultation, e.g. psychiatrist, psychologist, physiotherapist, occupational therapist, dietician, behavioral consultant | Geriatrician |
| Â | Casemanager |
Support and provide treatment to informal caregiver (optional) | Social worker |
Review prognosis and discharge destination (in some cases register patient at hospital replacement care facility) | Psychologist |
| Â | Geriatrician |
| Â | Geriatric nurse |
| Â | Nurse practitioner |
| Â | Social worker |
| Â | Transfer nurse |
| Â | Casemanager |
Weekly telephone consultation informal caregiver | Casemanager |
Hand out flyer 'PReCaP Recovery Team' to patient | Casemanager |
Exit interview with patient and informal caregiver | Transfer nurse |
Hand out flyer 'Prevention and Reactivation Centre' to patient (if transfer to PRC) | Transfer nurse |
Handover GAS care plan to physician hospital replacement care facility | Casemanager or geriatrician |
Home visit and support after hospital discharge until six months after hospital admission, including optional therapy | Casemanager |
Prevention and Reactivation Centre | Â |
Admission to PRC (including GAS care plan/medical handover) | Nurse practitioner |
Review GAS care plan | Nursing home physician or nurse practitioner |
Physical examination | Nursing home physician |
Intake patient/informal caregiver | Nurse |
Weekly Multidisciplinary Team Meeting: | Nursing home physician (coordinator) |
• First MTM after one week admission PRC | Nurse practitioner Casemanager Psychiatrist (in consultation) |
• Review progress and adjust GAS care plan | Social worker (in consultation) |
• Casemanager home care attends MTM in week 9 | Clinical geriatrician (in consultation) |
Introduction and intake patient | Nurse |
Treatment according to GAS care plan | Consulted disciplines |
If needed additional treatment by PReCaP recovery team and other disciplines if indicated, e.g. behavioral therapist, dietician, music therapist, dance therapist, visual arts therapist | Casemanager |
Hand over diary to patient (incl. therapy appointments and treatment information) | Nurse |
Support with activities according to diary | Nurse |
Specialized nursing home care within the socio-therapeutic environment, e.g. psychologist, physiotherapist (3 times a week), occupational therapist, speech therapist, dietician, behavioral therapist, music therapist, dance therapist, visual arts therapist, social worker | Casemanager |
Review medication use | Nursing home physician |
Support informal caregiver | Psychologist Casemanager |
Assessment of Motor and Process Skills | Occupational therapist |
Before discharge home visit (in week 9) | Occupational therapist |
If needed consultation external expertise, e.g. ophthalmologist, otolaryngologist, (orthopedic) surgeon, psychiatrist, neurologist, dermatologist, rehabilitation specialist | Nursing home physician |
If needed short term admission to psychiatric hospital or re-admission to hospital | Nursing home physician |
Hand out flyer 'PReCaP route after discharge' | Casemanager |
At discharge: write-up report GAS care plan, including advice additional treatment aimed at function preservation in the home environment | Nursing home physician (coordinator) |
| Â | Nurse practitioner Casemanager Psychiatrist (in consultation) |
| Â | Social worker (in consultation) |
| Â | Clinical geriatrician (in consultation) |
At discharge: write-up discharge letter | Nursing home physician Nurse practitioner |
At discharge: write-up handover | Involved disciplines |
At discharge: handover care plan to general practitioner | Casemanager |
If home care after PRC discharge: intake casemanager homecare in the presence of casemanager PReCaP ('warm handover') | Casemanager |