Table 1 Overview of initiatives on early detection and intervention for older people in the Netherlands

1. Initiatives by Elderly Health Centres [63–66]

Varies per initiative: target populations based on for example age, SES, health insurer, location of health care use

To prevent or early detect physical and psychological problems in (frail) older people

Varies per initiative: Home care organisation, municipal mental health care organisation, GP, nurse practitioner, community nurse

Varies per initiative: Community nurse, Municipal Health Services, (occupational) physician, community psychiatric nurse

Physical, psychological and social functioning

Provision of information and advice on lifestyle, preservation of independence and control. Referral to other professionals if necessary

Varies per initiative: For example: an instrument covering 3 domains: 1. Screening for frailty (Groningen Frailty Indicator); 2. Screening for health problems (Intermed) 3. Screening for wellbeing (Groningen Wellbeing Indicator)

Various locations were identified across the Netherlands. Per elderly health centre, a varying group of people was exposed to the initiative (e.g. a whole community; only people from certain GP practices; people affiliated with a specific health insurer)

2. Informative home visit by volunteers [67–69]

All people in a municipality who are 75 years and older

To bring community services to the attention of older people and to detect unidentified problems

Volunteer from welfare/volunteer organization

Welfare/volunteer organization, professional elderly advisor

Health, wellbeing, living circumstances, social participation

Provision of advice on services that can facilitate self-reliance and participation

Screening instruments are often not used. In some municipalities, a questionnaire or list with topics regarding activities, social relations, mobility, finances, nutrition is used

Informative home visits are offered by local welfare organisations in various municipalities across the Netherlands. Within those municipalities, every person over 75 years is exposed

3. Initiatives by GP practices [23, 24, 51, 70–74]

Older people living at home, who are at high risk of frailty. Age categories differ per initiative, e.g. people aged 65 and over; people aged 75 and over.

To identify frail older people in the population, and provide proactive care if necessary

Primary care

GP, nurse practitioner, community nurse. Other health and social care professionals if necessary, according to the problems that are identified.

Physical, psychological and social functioning

Design and execute a personal care and support plan

Varies per initiative: Screening methods for frailty, e.g. GP registries, screening instruments such as Groningen Frailty Indicator.

At least 8 types of initiatives were identified that were practiced in various locations in the Netherlands. The initiatives included approximately 170 practices and approximately 16.300 (frail) older people were exposed to the initiatives

Screening instruments for problems and risks related to health, wellbeing and living circumstances, e.g. Resident Assessment Instrument, EASY-Care TOS

4. Initiatives in hospitals and during hospital transfers [22, 75, 76]

Patients over 65 who are at high risk for loss of function during hospitalisation

To prevent loss of function during and after hospitalisation

(Research) nurse in hospital

Geriatric nurse, transfer nurse, geriatrician, case manager. Other health and social care professionals if necessary, according to the problems that are identified

Preservation of functioning, self-reliance and quality of life

Delivery of proactive care during hospitalisation combined with coordinated after care after hospital discharge

Varies per initiative: ISAR-HP, VMS (for screening frailty). GAS-plan, geriatric assessment (for screening for problems and risks)

At least 2 types of initiatives were identified in hospitals in the south-west and north-west of the Netherlands. Based on these initiatives, a minimum of 500 older people were exposed to the initiatives

5. Initiative by health and social care professionals who visit older people at their homes [77]

Older people living at home who are frail or at risk of frailty

To early detect psychosocial problems and risks

Health and social care professionals who visit older people at their homes, e.g. nurse from a home care organization, VEA, community nurse

Professionals from municipal (mental) health care organization, nurse from a home care organization, VEA, community nurse

Psychosocial problems and risks (e.g. loneliness, depression, alcoholism, elderly abuse)

Referral to the required services for their psychosocial issues

Screening instruments are used by some professionals (e.g. the Geriatric Depression Scale, GDS). Professionals mostly use their “gut-feeling”

This initiative was identified in one area in the south-west of the Netherlands

6. Initiatives by community nurses/integrated neighbourhood approach [78–80]

Varies per initiative: the community in general. Some of the initiatives are targeted at frail older people

To gain insight into the problems and needs in a community and facilitate people to keep control over their own lives

Community nurse (sometimes in combination with other professionals that are active in the community, e.g. social workers, district policemen)

Various health and social care professionals, according to the problems and needs that are identified

Various domains. For older people mainly health, wellbeing, safety and living situation

Provision of information, practical support, after care; referral to other professionals; facilitation of involvement of family caregivers

In some initiatives screening instruments are used. An “open conversation” without using any instruments is often preferred.

Initiatives by community nurses are offered in various neighbourhoods across the Netherlands

7. Home visits by volunteer elderly advisors (VEA) [81, 82]

Older people needing help, who contacted the elderly organisation

To facilitate self-reliance by offering practical support and contacting professionals if necessary

Initiated by older person or someone in his social network

VEA, others professionals according to the problems and needs that are identified

Health, wellbeing, living circumstance, participation

Provision of advice and practical support

In some cases, a topic list is used, but screening instruments are mostly not used. An “open conversation” without using any instruments is preferred.

VEAs are active through elderly organisations or local welfare organisations in various municipalities across the Netherlands.

8. Home visits by municipalities (so-called “kitchen-table conversations”). [83]

Older people living at home who requested support from municipal services and facilities

To evaluate the extent to which older people are self-reliant and able to participate in society, the support they receive from their social network, and the care and support that would be necessary from the municipality. All intended to facilitate self-reliance and social participation.

Initiated by older person, possibly in consultation with professional

Several possibilities, but always commissioned by municipality: social care consultant of the municipality, employee from (social) welfare organization, client support organization, health care organization.

All life domains (e.g. living, working, income/debt, education, health, lifestyle, leisure activities, social activity, mobility, practical skills).

Provision of support from municipal social services (e.g. home care, adult day care services) if older people are not self-reliant or able to independently, or with the support from their social network, participate in society.

Varies per municipality, e.g. Self-reliance matrix (ZRM) and the Vitality Indicator

In principle in all municipalities in the Netherlands. However, due to large reforms of the long-term care system (that involve municipalities), not all municipalities are able to offer kitchen table conversations yet.