Article

This series of articles for rehabilitation in practice aims to cover a knowledge
element of the rehabilitation medicine curriculum. Nevertheless they are intended
to be of interest to a multidisciplinary audience. The competency addressed in
this article is 'The trainee consistent demonstrates a knowledge of how evidence
based methods and strategies can be incorporated in an integral and
multidisciplinary programme for community-dwelling frail elderly.' Abstract
Objective: To describe and justify a primary care interdisciplinary programme for
community-dwelling frail older people aimed to prevent disability. Background:
Disability is a negative outcome of frailty among older persons. Policy reports
and research studies emphasize the need for programmes to reduce disability
progression. Between 2008 and 2010 we developed such a programme. Development:
Following the Intervention Mapping protocol, a research team and a
multidisciplinary professional developed the programme. Literature reviews and an
expert meeting led to identification of basic elements, theory-based methods and
practical tools. The programme: The general practitioner and the practice nurse
comprise the core team that can be extended by other professionals such as
occupational and physical therapist. The programme includes six steps: (1)
screening, (2) assessment, (3) analysis and preliminary action plan, (4)
agreement on an action plan, (5) execution of the action plan (toolbox parts) and
(6) evaluation and follow-up. The main features are: identifying risks for
developing disability and targeting risk factors using professional standards and
the 5A Behavioural Change Model to support self management, and identifying
problems in performing activities and enhancing meaningful activities based on
the Model of Human Occupation. Screening, individual assessment, tailor-made and
client-centred care, self-management support, case management and
interdisciplinary cooperation are important principles in delivering the
programme. Discussion: The disability-prevention programme seems promising for
addressing the needs of frail older people for independent living and for
targeting risk factors. Its feasibility and effects are currently being tested in
a randomized controlled trial.

Langue : ANGLAIS