Skip to main content

Table 1 The PROSPER template for intervention description and replication—TIDieR

From: Implementing personalised care planning for older people with frailty: a process evaluation of the PROSPER feasibility trial

Procedures

 1. The key components of the intervention are the ‘guided conversation’ and ‘graduation’ as delivered by the Personal Independence Co-ordinator (PIC)

 2. Following consent and baseline assessment, intervention practices send letters of invitation to registered participants, branded with both the practice and Age UK logos, to offer the PCP intervention

 3. Unless the participant has contacted the surgery to ‘opt out’, the PIC follows-up with a phone call 5–10 days after the letter has been sent out. The purpose of the phone call is to discuss the personalised care planning service in more detail and arrange a convenient time for the first visit

 4. Before the first visit the PIC records a minimum amount of personal information from the patient’s Electronic Health Record

 5. The first meeting should take place approximately one week after the initial phone call, if possible. The main focus of this visit is on information sharing and relationship building. This visit will;

  ○ Make it clear that the service is time limited in order to manage expectations

  ○ Let the older people know that they may receive on-going support from the Support Worker alongside the PIC

  ○ Note any key contacts

  ○ Outline what support is and is not on offer and, importantly, when it is on offer i.e. Monday to Friday during office hours

  ○ Leave the summary information booklet in for the older people to read

  ○ Complete and leave the quick reference fridge magnet. An expected end date should be recorded on the magnet to remind the older people that contact time is limited

 6. A second visit is then scheduled within one week. The focus of the second visit is to co-produce an action plan with older people, through a ‘guided conversation’ which will incorporate ascertaining information about: a usual day; support networks; social networks; mobility and transport; health and fitness; safety and security; finances & paperwork and use of statutory support providers

 7. An action plan based on the older people goals is co-produced with the older people. The action plan will record: the goal; importance of the goal; confidence in achievement of the goal; motivation to achieve the goal; enablers to achieve the goal and the target date for achievement of the goal

 8. The wider PCP team – PIC and Support Worker—work with the older people to achieve the goals set out in the action plan

 9. Information about the older people is fed-back to the primary care Multi-disciplinary Team (MDT) and significant outputs recorded in their electronic health care records (systmone, EMIS, VISION etc.)

 10. A review of the Action Plan takes place at two months. Older people are reminded of the expected end date of the intervention

 11. A final review takes place at 12 weeks. The current status of goal achievement is recorded; delays in goal achievement due to delays with third parties noted

 12. Older people ‘graduate’ from the service after a period of approximately 12 weeks. The ‘graduation’ session provides an opportunity for the older people and PIC workers to discuss future options including a step down in support and routes to re-engagement with services if necessary in the future

Provider

 1. Screening for eligible older people is undertaken by administrative staff within general practices

 2. Potential older people are reviewed by GPs with in-depth knowledge of the practice list. All practice staff receive proportionate GCP training to ensure adherence to the trial protocol

 3. Guided conversations and graduations are undertaken by Personal Independence Co-ordinators employed by local Age UK offices

 4. Support to the older people during the intervention period is provided by the PIC and Support Worker depending on the specific type of support required. Support may also be provided by friends and family or other statutory or third sector organisations

Delivery mechanism

 1. The intervention is delivered by a trained team of Personal Independence Co-ordinators

 2. The intervention is aimed at an individual but if appropriate an individual’s carer/spouse may be involved in the development of the action plan

 3. Specific behavioural change techniques are employed to facilitate the older people in achieving their goals

 4. Support is offered face to face or via email and/or telephone, as appropriate

 5. Practices will allow PIC workers access to electronic health care records in order to record pertinent information for the MDT members

 6. Practices will hold MDTs at least every 4 weeks in order for the PIC to feedback on action plan progress and raise any specific issues that need to be addressed by other MDT members

Delivery location

 1. The intervention is delivered in the participants own home, in communities and via the telephone and/or email, where appropriate

Duration and Intensity

 1. The intervention is delivered over a period of approximately 12 weeks depending on the specific needs of the older people

 2. Face to face contact is made at the start (approximately 90 min) and the end of the intervention (approximately 45 min) with telephone follow up and hands on support in achieving goals given if necessary. A two month review of action plan progress is also conducted face to face

Tailoring

 1. PCP is designed to be person centred and tailored to individual older people needs and circumstances

 2. The Action Plan remains a dynamic document and goals may be added/amended throughout the period of engagement