Heaven Anne, Foster Marilyn, Foy Robbie, Hawkins Rebecca, Hulme Claire, Humphrey Sara, Smith Jane, Clegg Andrew Paul
Academic Unit of Ageing and Stroke Research, University of Leeds, Bradford Institute for Health Research, Bradford Teaching Hospitals NHS Foundation Trust, Bradford, UK
Humber Teaching NHS Foundation Trust, Beverley, UK.
BJGP Open. 2025 Apr 24;9(1). doi: 10.3399/BJGPO.2024.0163. Print 2025 Apr.
Frailty increases vulnerability to major health changes because of seemingly small health problems. It affects around 10% of people aged >65 years. Older adults with frailty frequently have multiple long-term conditions, personal challenges, and social problems. Personalised care planning (PCP) based on 'goal setting' and 'action planning' is a promising way to address the needs of older adults living with frailty.
To identify and explore factors that influence the implementation of PCP-style interventions for older adults.
DESIGN & SETTING: We conducted a scoping review and identified a small number of interventions that explicitly employed goal setting and action planning.
We used a range of sources to identify relevant material. We included all interventions inclusive of patients aged ≥65 years and reported in English. We excluded end-of-life care interventions, group education, and/or those that did not involve one-to-one engagement. We explored all related articles that described, examined, or discussed implementation. We constructed a thematic framework in NVivo (version 11). Findings were narratively synthesised.
We identified 18 potentially relevant PCP-style interventions and 13 of these met the inclusion criteria. Within these, were seven main categories of potentially modifiable influences relevant to older adults with frailty related to the following: primary care engagement; delivery staff characteristics; training; patient engagement; collaborative working; organisation and management; and systems.
Many modifiable factors can influence the implementation of PCP. We identified several influences that have informed the development and implementation of a novel intervention PeRsOnaliSed care Planning for oldER people with frailty (PROSPER).
由于看似微小的健康问题，身体虚弱会增加对重大健康变化的易感性。它影响着约10%的65岁以上人群。身体虚弱的老年人经常患有多种长期疾病、个人挑战和社会问题。基于“目标设定”和“行动计划”的个性化护理计划（PCP）是满足身体虚弱的老年人需求的一种有前景的方法。
识别并探索影响针对老年人实施PCP式干预措施的因素。
我们进行了一项范围综述，确定了少数明确采用目标设定和行动计划的干预措施。
我们使用了一系列来源来识别相关材料。我们纳入了所有涉及≥65岁患者且以英文报道的干预措施。我们排除了临终关怀干预措施、团体教育和/或那些不涉及一对一接触的措施。我们探索了所有描述、检查或讨论实施情况的相关文章。我们在NVivo（第11版）中构建了一个主题框架。研究结果进行了叙述性综合。
我们确定了18项潜在相关的PCP式干预措施，其中13项符合纳入标准。在这些措施中，有七大类与身体虚弱的老年人相关的潜在可改变影响因素，涉及以下方面：初级保健参与度；提供服务人员特征；培训；患者参与度；协作工作；组织与管理；以及系统。
许多可改变因素会影响PCP的实施。我们确定了一些影响因素，这些因素为一项新的干预措施——针对身体虚弱老年人的个性化护理计划（PROSPER）的开发和实施提供了参考。
