Facing Frailty : Exploring the effectiveness of integrated care for frail older people

Integrated care is advocated as a promising solution to overcome barriers in the fragmented health care system for complex populations as frail older people. However, it remains unclear whether integrated care can meet the high and diverse expectations. The aim of this thesis was therefore to explore the (cost-)effectiveness of preventive, integrated care for community-dwelling frail older people.
Part A of this thesis focuses on the Walcheren Integrated Care Model (WICM), a comprehensive intervention combining evidence-based elements, involving geriatric assessments, case management, multidisciplinary teams, a single entry point, multidisciplinary protocols and discussions, web-based patient files, and a provider network into one intervention. It focuses on the entire chain of healthcare delivery, from detection to the provision of care, within prevention, cure, care, welfare and residence and in the area of in primary, secondary and tertiary care. The evaluation study of the WICM had a quasi-experimental design with before and after measurements, at three and twelve months. Data was collected by questionnaires– all frail older people were visited by trained interviewers -, GP file research and time registrations from case managers. The evaluation study showed that the WICM had a positive effect on the dimension love and friendship and, furthermore, a moderately positive effect on general quality of life. Nevertheless, no effects were found on health outcomes and functional abilities and the WICM was not cost-effective.
Part B of this thesis critically reflects the concepts and methodologies used to explore the (cost-) effectiveness of integrated care for frail older. A systematic review, including 46 studies on 29 interventions revealed that the majority of the outcomes showed no significant effects. Moreover, the heterogeneity within the population of frail older people is further explored in this thesis by developing frailty profiles based on the data 43,000 older people. Six profiles were distinguished ranging from relatively healthy to multi-frail and showed that the frail older person does not exist. The effectiveness of integrated care was determined for each of the six frailty and showed that no effects were substantiated in terms functional limitations, mental health, social functioning, health-related quality of life and general quality of life.
Integrated care could be more properly aligned to the target population of frail older people. Integrated care interventions in primary care settings remain characterized by medical dominance, whereas, a more holistic and person-centered approach might be required. Moreover, prevention might be integrated more carefully within the integrated care interventions. Effective integrated care also requires research that is integrated, continuous, and person-centred to cover the complexities of daily practice. Bridges should be built between research, practice and policy and also researchers should work together more closely.