Faculty of Health and Care, Zuyd University of Applied Sciences, Heerlen, The Netherlands.
Clin Rehabil. 2011 Nov;25(11):963-74. doi: 10.1177/0269215511410728. Epub 2011 Aug 17.
To describe and justify a primary care interdisciplinary programme for community-dwelling frail older people aimed to prevent disability.
Disability is a negative outcome of frailty among older persons. Policy reports and research studies emphasize the need for programmes to reduce disability progression. Between 2008 and 2010 we developed such a programme.
Following the Intervention Mapping protocol, a research team and a multidisciplinary professional developed the programme. Literature reviews and an expert meeting led to identification of basic elements, theory-based methods and practical tools. THE PROGRAMME: The general practitioner and the practice nurse comprise the core team that can be extended by other professionals such as occupational and physical therapist. The programme includes six steps: (1) screening, (2) assessment, (3) analysis and preliminary action plan, (4) agreement on an action plan, (5) execution of the action plan (toolbox parts) and (6) evaluation and follow-up. The main features are: identifying risks for developing disability and targeting risk factors using professional standards and the 5A Behavioural Change Model to support self management, and identifying problems in performing activities and enhancing meaningful activities based on the Model of Human Occupation. Screening, individual assessment, tailor-made and client-centred care, self-management support, case management and interdisciplinary cooperation are important principles in delivering the programme.
The disability-prevention programme seems promising for addressing the needs of frail older people for independent living and for targeting risk factors. Its feasibility and effects are currently being tested in a randomized controlled trial.
描述和论证一个针对社区居住的虚弱老年人的初级保健跨学科计划，旨在预防残疾。
残疾是老年人虚弱的负面结果。政策报告和研究强调需要制定方案来减缓残疾进展。我们在 2008 年至 2010 年期间开发了这样一个方案。
根据干预映射协议，一个研究团队和一个多学科专业人员制定了该方案。文献回顾和专家会议导致确定了基本要素、基于理论的方法和实用工具。
全科医生和执业护士组成核心团队，可以由其他专业人员（如职业治疗师和物理治疗师）扩展。该方案包括六个步骤：（1）筛查，（2）评估，（3）分析和初步行动计划，（4）达成行动计划，（5）执行行动计划（工具包部分）和（6）评估和随访。主要特点是：使用专业标准和 5A 行为改变模型识别发展残疾的风险和目标风险因素，以支持自我管理，并根据人类作业模型识别活动执行中的问题和增强有意义的活动。筛查、个体评估、量身定制和以客户为中心的护理、自我管理支持、病例管理和跨学科合作是提供该方案的重要原则。
该残疾预防方案似乎有希望满足虚弱老年人独立生活的需求，并针对风险因素。其可行性和效果目前正在一项随机对照试验中进行测试。
