Identifying and Managing Frailty in the Elderly in a Multiprofessional Health Home
Overview
- Phase
- N/A
- Intervention
- Quality of life test
- Conditions
- Elderly, Frail
- Sponsor
- University Hospital, Rouen
- Enrollment
- 120
- Primary Endpoint
- Evaluate the effect of implementing a personalized healthcare plan (PPS) on patient quality of life at M24
- Status
- Not Yet Recruiting
- Last Updated
- 5 days ago
Overview
Brief Summary
"Healthy ageing" is not limited to the absence of disease, but implies the "development and maintenance of the functional skills that enable the elderly to enjoy a state of well-being": (for example : the ability to walk, go out, engage in leisure activities, memorize...) It is interesting to study whether the implementation of a Personal Health Plan (PHP) in a Multiprofessional Health Home improves the quality of life of frail elderly people.
Detailed Description
"Healthy ageing" is not limited to the absence of disease, but implies the "development and maintenance of the functional skills that enable the elderly to enjoy a state of well-being": (for example : the ability to walk, go out, engage in leisure activities, memorize...) Between "good health" and "dependence", there is a precarious, reversible state of transition known as frailty. There are several simple tools for identifying frailty, such as the GFST (Gerontopole Frailty Screening Tool). The Gerontopole Frailty Screening Tool and the Fatigue, Resistance, Ambulation, Illness, Loss of Weight questionnaire have proved more sensitive. The gold standard for diagnosing and assessing frailty is a comprehensive geriatric assessment based on the multidimensional model of the Standardized Geriatric Assessment (SGA). Its aim is to identify all the medical, functional, psychological and social problems that may affect a frail elderly patient, in order to set up a long-term follow-up project, taking into account the patient's needs. It is interesting to study whether the implementation of a Personal Health Plan in a Multiprofessional Health Home improves the quality of life of frail elderly people.
Investigators
Eligibility Criteria
Inclusion Criteria
- •Patient ≥ 70 years
- •Autonomous patient (ADL ≥ 5)
- •Patient identified as frail according to the Gérontopôle de Toulouse GFST grid
- •Patient whose primary care physician is in the MSPs of Charleval or Romilly sur Andelle for the intervention group, and in the MSPs of Gaillon and Pont de l'Arche for the control group.
- •Patient living at home or in an RPA
- •Understanding of the French language
- •Patient having read and understood the information letter and signed the consent form
- •Affiliation with a social security scheme
Exclusion Criteria
- •Hospital geriatric follow-up
- •Geriatric assessment already carried out
- •Person deprived of liberty by an administrative or judicial decision, or placed under court protection / sub-guardianship or curatorship
- •History of illness or psychological or sensory abnormality likely to prevent the subject from fully understanding the conditions required for participation in the protocol, or from giving informed consent.
Arms & Interventions
Group 1 Interventional Arm (with PHP)
The patient will have a standardized geriatric assessment carried out by a nurse in both Multiprofessional Health Home. This geriatric assessment will be used to draw up a summary with different objectives and priorities, which will then be discussed at a multi-professional consultation meeting in the month following the geriatric assessment. The first multi-professional consultation meeting (MCM) will present the summary of the geriatric assessment and discuss the care and assistance to be implemented in the Personalized Health Plan (PHP). The Personalized Health Plan will then be prepared and formalized by the nurse, in partnership with the other healthcare professionals involved in the Personalized Health Plan. It will be presented to and validated by the patient and his/her carer. The actions will then be implemented.
Intervention: Quality of life test
Group 2 Control Arm (without PHP)
In the control group, the attending physician will set up appropriate care for a patient identified as frail in a standard general medical care pathway, having been made aware of the patient's frailty at the time of inclusion. He or she will organize the patient's care, referring him or her to the appropriate specialists according to the difficulties identified at inclusion, and according to the patient's habits and network.
Intervention: Quality of life test
Outcomes
Primary Outcomes
Evaluate the effect of implementing a personalized healthcare plan (PPS) on patient quality of life at M24
Time Frame: 2 years
change in Study short Form -36 (SF-36) quality-of-life score between Inclusion (M0) and 2-year follow-up (M24). The SF-36 consists of 36 questions to assess quality of life related to general health. Each item is scored on a scale from 0 to 100, 0 and 100 representing the lowest and highest possible scores
Secondary Outcomes
- Patient's cognitive status at M6, M12 and M24(2 years)
- Patient quality of life at M6 and M12(1 year)
- Drug intake at M6, M12 and M24(2 years)
- Emergency room visits and hospitalizations at M6, M12 and M24(2 years)
- Therapeutic compliance at M6, M12 and M24(2 years)
- Falls and patient mobility at M6, M12 and M24(2 years)
- Patient nutritional status at M6, M12 and M24(2 years)
- Patient's emotional state at M6, M12 and M24(2 years)
- Patient's social fragility at M6, M12 and M24(2 years)
- Patient autonomy at M6, M12 and M24.(2 years)