INNOVATIVE TEAM-BASED GERIATRIC CO-MANAGEMENT FOR FRAIL OLDER PATIENTS IN THE NETHERLANDS

摘要

In Zuyderland Medical Center we conducted a study aiming to prevent complications and functional decline during hospital stay. Main conclusion: comprehensive geriatric assessment at admission and delivery of advices by a geriatric consultation team was not sufficient: the recommended interventions were often not executed. This led to a new model: co-management for frail elderly at risk for functional loss. This model is currently being implemented and evaluated in a surgical, internal medicine and pulmonary ward. Main components of the program are: Comprehensive Geriatric Assessment, systematic medication review, a personalised nutrition and mobility program, specific role of the geriatric resource nurse, a physiotherapist (specialization Geriatrics), daily rounds of the geriatric team and participation in multidisciplinary rounds, the Transitional Care Bridge Program and continuity of care after discharge and follow up at the polyclinic geriatric medicine. In this presentation structure, process and first results of this approach will be presented.