1. CareWell-primary care Integrated care for community dwelling frail elders Franca Ruikes, MD/GP, PhD candidate HJ Schers, SU Zuidema, WJ Assendelft, RTCM Koopmans

2. (Double) Ageing Austerity plans Complex and changing needs of frail elders; From disease-control to self-reliance and quality of life -> Integration of cure, care and welfare

3. Health-and information portal; Shared EPD + Communication tool CareWell-primary care program

4. Is the CareWell-primary care program* effective in improving Functioning (Katz-15 index sumscore) and Quality of life (EQ5D+C) of community-dwelling frail elders? *Ruikes FGH et al. The CareWell-primary care program: design of a cluster controlled trial and process evaluation of a complex intervention targeting community-dwelling frail elderly. BMC Fam Pract.BMC Fam Pract. 2012 Dec 5;13:115.

5. Design and Methods Cluster controlled non-randomized trial: 6 GP practices in both intervention- and control group 50 Frail elders (participants) clustered per practice; Screening on frailty with the EasyCare-TOS instrument * (GCA) Follow up of 12 months * Van Kempen et al. (2013). "Development of an instrument for the identification of frail older people as a target population for integrated care." Br J Gen Pract 63(608): e225-231.

6. Subjects CharacteristicIntervention N=287Control N=249 Age, mean83.180.5 Female sex67%64% Living alone63%*55%* Socio-economic status score 0.5*0.2* Cognition score7.5*5.3* Katz 15 index sum-score5.4*4.6* EQ5D+C score0.6 Mental health score61.162.4 Limited social functioning 88%*92* Frailty index0.4 Care-complexity21%*30%* * P < 0.05

7. Results OutcomeIntervention groupControl groupEffect coefficient (95% CI) P- value Base line (SD) FU mean change (SD) Base Line (SD) FU mean change (SD) Katz 15 index sumscore 5.4 (2.9) 0.8 (1.9)4.6 (2.7) 0.5 (2.1)0.4 (-0.1; 0.8)0.10 EQ5D+C0.6 (0.3) 0.0 (0.3) 0.6 (0.3) 0.0 (0.3)0.0 (-0.1; 0.0)0.37

8. Conclusions The CareWell-primary care program is ineffective on functioning and QoL Implementation takes time! Relation degree/fidelity of implementation and effect? Already strong Dutch primary care system Responsiveness Katz-15 and EQ5D in frail elderly?