Groos Sara S, Tan Stefanie M, Linn Annemiek J, Kuiper Judith I, van Schoor Natasja M, van Weert Julia C M, van der Velde Nathalie
Internal Medicine, Section of Geriatric Medicine, Amsterdam UMC Location University of Amsterdam, Amsterdam, The Netherlands.
Amsterdam Public Health Research Institute, Amsterdam, The Netherlands.
Eur Geriatr Med. 2025 Feb;16(1):229-236. doi: 10.1007/s41999-024-01142-3. Epub 2025 Jan 9.
Multidisciplinary care pathways for falls prevention, which include falls risk stratification, multifactorial falls risk assessment, and management of multidomain interventions, can reduce falls in older adults. However, efficient multidisciplinary falls prevention care is challenging due to issues such as poor communication and role allocation. This study aimed to identify and visualize the multidisciplinary care needs of primary care-based health care professionals (HCPs) for falls prevention in the Netherlands using the novel co-design approach of journey mapping.
Online focus groups and interviews (N = 45) were conducted with physical therapists (n = 15), district nurses (n = 9), occupational therapists (n = 7), pharmacists (n = 6), nurse practitioners (n = 5), podiatrists (n = 2), and one general practitioner. HCPs were asked about their interactions, experiences, needs, and barriers with regards to multidisciplinary falls prevention care in a primary care context. Insights were used to visualize a journey map depicting the desired future state of multidisciplinary care pathways for falls prevention.
Journey mapping identified the following needs for effective multidisciplinary falls prevention care: a dedicated case manager after risk stratification, preparatory patient information before the assessment, small multidisciplinary care team for the assessment, patient involvement during intervention management, good communication between HCPs, and a reduction in workload for HCPs.
The inclusion of a case manager program for older adults and access to resources to facilitate good communication between HCPs are important to optimize the configuration of multidisciplinary care pathways for falls prevention in actual practice.
预防跌倒的多学科护理路径,包括跌倒风险分层、多因素跌倒风险评估以及多领域干预措施的管理,可减少老年人跌倒。然而,由于沟通不畅和角色分配等问题,高效的多学科跌倒预防护理具有挑战性。本研究旨在使用新颖的旅程映射协同设计方法,识别并可视化荷兰基层医疗保健专业人员(HCPs)在预防跌倒方面的多学科护理需求。
对物理治疗师(n = 15)、社区护士(n = 9)、职业治疗师(n = 7)、药剂师(n = 6)、执业护士(n = 5)、足病医生(n = 2)和一名全科医生进行了在线焦点小组讨论和访谈(N = 45)。询问HCPs在基层医疗环境中关于多学科跌倒预防护理的互动、经验、需求和障碍。这些见解被用于可视化一幅描绘预防跌倒多学科护理路径理想未来状态的旅程图。
旅程映射确定了有效开展多学科跌倒预防护理的以下需求:风险分层后设立专门的个案管理员、评估前准备患者信息、组建小型多学科护理团队进行评估、干预管理期间患者参与、HCPs之间良好沟通以及减轻HCPs的工作量。
纳入针对老年人的个案管理计划以及获取有助于HCPs之间良好沟通的资源,对于在实际实践中优化预防跌倒多学科护理路径的配置非常重要。