Abstract
Background: Meeting the complex medical needs of the growing group of community dwelling older adults is a global challenge. This study explores one possible solution to this challenge, the collaboration between the general practitioner (GP) and a specialist in the medical care of older adults (elderly care physician, ECP). Additional goals of these collaborations are to promote the quality of life of patients and informal caregivers, to prevent hospital and nursing home admissions, and save costs.
The objective of this study is to develop a generic model of care for community-dwelling elderly with complex multimorbidity, which can be adapted to the regional or local context, supported by adequate funding, and can be effectively implemented in other settings.
Approach: While collaborations between GP’s and ECP’s have emerged across the Netherlands, there is variability in approaches, a lack of clear quality frameworks, and funding is experienced to be insufficient.
A prospective cohort study is being conducted across six regions in the Netherlands, involving patients receiving this type of collaborative care. Both quantitative and qualitative data are being collected from 150 patients, and their stakeholders (ECP’s, GP’s, and caregivers). Data collection encompasses the patient's care needs and treatment goals as reported by the patient and their caregivers, patient characteristics, types of care provided, intervention costs, and satisfaction levels. Data collection commenced in February of 2024, with baseline data collection completed in December 2024 and follow-up data completed in March 2025.
To ensure that the perspectives of those directly affected by the care model are considered, we actively engage ECP’s and other (policy) stakeholders in the design and execution of the study. We achieve this by organizing various learning network meetings, during which knowledge is exchanged among stakeholders and participants.
Results: Preliminary results, based on approximately 45 patients, show that in many cases, the collaboration is initiated by the GP due to a need of cognitive diagnostics and decline in physical functioning. On average ECPs and their team spend approximately 9 hours on each case. However, the duration and intensity of the involvement of the ECP and their team vary across the different regions. For most cases, ECPs describe employing four previously described functionalities, namely: gaining insight, developing a care and treatment plan, accomplishing appropriate care, and aligning and coordinating objectives. Despite a low to fair level of agreement on initial treatment goals between the various stakeholders, the stakeholders indicated their goals were met and they were satisfied with the provided care.
Implications: Although inclusion and data collection is ongoing, preliminary results paint a positive picture, in line with results of earlier studies of this collaboration. This highlights the potential of these types of medical collaborations as a solution to the global challenge of the complex medical care of community dwelling older adults. The results of this study will be used to inform the development of a generic model and quality framework for this type of care in order to inform policy and achieve appropriate and comprehensive funding for these collaborations.