Effectiveness of a Geriatric Care Model for frail older adults in primary care: Results from a stepped wedge cluster randomized trial

Published:November 17, 2015DOI:


      • Primary care-based comprehensive care may improve outcomes in frail older adults.
      • We investigated effects of the Geriatric Care Model (GCM) on quality of life and other outcomes.
      • The GCM combines tailored care based on geriatric assessments with management by geriatric expert teams.
      • We found no significant differences between the intervention group and usual care.
      • The GCM adds very little to usual primary care for this population.



      Primary care-based comprehensive care programs have the potential to improve outcomes in frail older adults. We evaluated the impact of the Geriatric Care Model (GCM) on the quality of life of community-dwelling frail older adults.


      A 24-month stepped wedge cluster randomized controlled trial was conducted between May 2010 and March 2013 in 35 primary care practices in the Netherlands, and included 1147 frail older adults. The intervention consisted of a geriatric in-home assessment by a practice nurse, followed by a tailored care plan. Reassessment occurred every six months. Nurses worked together with primary care physicians and were supervised and trained by geriatric expert teams. Complex patients were reviewed in multidisciplinary consultations. The primary outcome was quality of life (SF-12). Secondary outcomes were health-related quality of life, functional limitations, self-rated health, psychological wellbeing, social functioning and hospitalizations.


      Intention-to-treat analyses based on multilevel modeling showed no significant differences between the intervention group and usual care regarding SF-12 and most secondary outcomes. Only for IADL limitations we found a small intervention effect in patients who received the intervention for 18 months (B = −0.25, 95%CI = −0.43 to −0.06, p = 0.007), but this effect was not statistically significant after correction for multiple comparisons.


      The GCM did not show beneficial effects on quality of life in frail older adults in primary care, compared to usual care. This study strengthens the idea that comprehensive care programs add very little to usual primary care for this population.

      Trial registration

      The Netherlands National Trial Register NTR2160.


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        • Ahmed N.
        • Mandel R.
        • Fain M.J.
        Frailty: an emerging geriatric syndrome.
        Am J Med. 2007; 120: 748-753
        • Christensen K.
        • Doblhammer G.
        • Rau R.
        • Vaupel J.W.
        Ageing populations: the challenges ahead.
        Lancet. 2009; 374: 1196-1208
        • Fried L.P.
        • Ferrucci L.
        • Darer J.
        • Williamson J.D.
        • Anderson G.
        Untangling the concepts of disability, frailty, and comorbidity: implications for improved targeting and care.
        J Gerontol A Biol Sci Med Sci. 2004; 59: 255-263
        • Lacas A.
        • Rockwood K.
        Frailty in primary care: a review of its conceptualization and implications for practice.
        BMC Med. 2012; 10: 4
        • Boult C.
        • Wieland G.D.
        Comprehensive primary care for older patients with multiple chronic conditions: “Nobody rushes you through”.
        JAMA. 2010; 304: 1936-1943
        • De Lepeleire J.
        • Iliffe S.
        • Mann E.
        • Degryse J.M.
        Frailty: an emerging concept for general practice.
        Br J Gen Pract. 2009; 59: e177-e182
        • Boult C.
        • Green A.F.
        • Boult L.B.
        • Pacala J.T.
        • Snyder C.
        • Leff B.
        Successful models of comprehensive care for older adults with chronic conditions: evidence for the Institute of Medicine's “retooling for an aging America” report.
        J Am Geriatr Soc. 2009; 57: 2328-2337
        • Beswick A.D.
        • Rees K.
        • Dieppe P.
        • et al.
        Complex interventions to improve physical function and maintain independent living in elderly people: a systematic review and meta-analysis.
        Lancet. 2008; 371: 725-735
        • Daniels R.
        • van Rossum E.
        • de Witte L.
        • Kempen G.I.J.M.
        • van den Heuvel W.
        Interventions to prevent disability in frail community-dwelling elderly: a systematic review.
        BMC Health Serv Res. 2008; 8: 278
        • de Bruin S.R.
        • Versnel N.
        • Lemmens L.C.
        • et al.
        Comprehensive care programs for patients with multiple chronic conditions: a systematic literature review.
        Health Policy. 2012; 107: 108-145
        • Coleman K.
        • Austin B.T.
        • Brach C.
        • Wagner E.H.
        Evidence on the Chronic Care Model in the new millennium.
        Health Aff. 2009; 28: 75-85
        • Adams S.G.
        • Smith P.K.
        • Allan P.F.
        • Anzueto A.
        • Pugh J.A.
        • Cornell J.E.
        Systematic review of the chronic care model in chronic obstructive pulmonary disease prevention and management.
        Arch Intern Med. 2007; 167: 551-561
        • Bodenheimer T.
        • Wagner E.H.
        • Grumbach K.
        Improving primary care for patients with chronic illness.
        JAMA. 2002; 288: 1775-1779
        • Bodenheimer T.
        • Wagner E.H.
        • Grumbach K.
        Improving primary care for patients with chronic illness: the chronic care model, Part 2.
        JAMA. 2002; 288: 1909-1914
        • Boult C.
        • Leff B.
        • Boyd C.M.
        • et al.
        A matched-pair cluster-randomized trial of guided care for high-risk older patients.
        J Gen Intern Med. 2013; 28: 612-621
        • Boorsma M.
        • Frijters D.H.M.
        • Knol D.L.
        • Ribbe M.E.
        • Nijpels G.
        • van Hout H.P.J.
        Effects of multidisciplinary integrated care on quality of care in residential care facilities for elderly people: a cluster randomized trial.
        CMAJ. 2011; 183: E724-E732
        • Muntinga M.E.
        • Hoogendijk E.O.
        • van Leeuwen K.M.
        • et al.
        Implementing the chronic care model for frail older adults in the Netherlands: study protocol of ACT (frail older adults: care in transition).
        BMC Geriatr. 2012; 12: 19
        • Hemming K.
        • Haines T.P.
        • Chilton P.J.
        • Girling A.J.
        • Lilford R.J.
        The stepped wedge cluster randomised trial: rationale, design, analysis, and reporting.
        BMJ. 2015; 352: h391
        • Campbell M.K.
        • Piaggio G.
        • Elbourne D.R.
        • Altman D.G.
        Consort 2010 statement: extension to cluster randomised trials.
        BMJ. 2012; 345e5661
        • Raiche M.
        • Hebert R.
        • Dubois M.F.
        PRISMA-7: a case-finding tool to identify older adults with moderate to severe disabilities.
        Arch Gerontol Geriatr. 2008; 47: 9-18
        • Schuurmans H.
        • Steverink N.
        • Lindenberg S.
        • Frieswijk N.
        • Slaets J.P.J.
        Old or frail: what tells us more?.
        J Gerontol A Biol Sci Med Sci. 2004; 59: M962-M965
        • Pialoux T.
        • Goyard J.
        • Lesourd B.
        Screening tools for frailty in primary health care: a systematic review.
        Geriatr Gerontol Int. 2012; 12: 189-197
        • Hebert R.
        • Raiche M.
        • Dubois M.F.
        • Gueye N.R.
        • Dubuc N.
        • Tousignant M.
        Impact of PRISMA, a coordination-type integrated service delivery system for frail older people in Quebec (Canada): a quasi-experimental study.
        J Gerontol B Psychol Sci Soc Sci. 2010; 65B: 107-118
        • Hoogendijk E.O.
        • van der Horst H.E.
        • Deeg D.J.H.
        • et al.
        The identification of frail older adults in primary care: comparing the accuracy of five simple instruments.
        Age Ageing. 2013; 42: 262-265
        • Hirdes J.P.
        • Fries B.E.
        • Morris J.N.
        • et al.
        Integrated health information systems based on the RAI/MDS series of instruments.
        Healthc Manage Forum. 1999; 12: 30-40
        • Brook R.H.
        • Ware J.E.J.
        • Davies-Avery A.
        • et al.
        Overview of adult health measures fielded in Rand's health insurance study.
        Med Care. 1979; 17: 1-131
        • Brooks R.
        EuroQol: the current state of play.
        Health Policy. 1996; 37: 53-72
        • Weinberger M.
        • Samsa G.P.
        • Schmader K.
        • Greenberg S.M.
        • Carr D.B.
        • Wildman D.S.
        Comparing proxy and patients' perceptions of patients' functional status: results from an outpatient geriatric clinic.
        J Am Geriatr Soc. 1992; 40: 585-588
        • Moorer P.
        • Suurmeije T.
        • Foets M.
        • Molenaar I.W.
        Psychometric properties of the RAND-36 among three chronic diseases (multiple sclerosis, rheumatic diseases and COPD) in The Netherlands.
        Qual Life Res. 2001; 10: 637-645
        • Hays R.D.
        • Morales L.S.
        The RAND-36 measure of health-related quality of life.
        Ann Med. 2001; 33: 350-357
        • van der Zee K.
        • Sanderman R.
        Het meten van de algemene gezondheidstoestand met de RAND-36, een handleiding.
        ([In Dutch]) UMCG/Rijksuniversiteit Groningen, Groningen2014 ([ Accessed June 4, 2015])
        • Lutomski J.E.
        • Baars M.A.E.
        • Schalk B.W.M.
        • et al.
        The development of the Older Persons and Informal Caregivers Survey Minimum DataSet (TOPICS-MDS): a large-scale data sharing initiative.
        PLoS One. 2013; 8e81673
        • Lutomski J.E.
        • Baars M.A.E.
        • van Kempen J.A.
        • et al.
        Validation of a frailty index from the older persons and informal caregivers survey minimum data set.
        J Am Geriatr Soc. 2013; 61: 1625-1627
        • Kriegsman D.M.
        • Penninx B.W.
        • van Eijk J.T.
        • Boeke A.J.
        • Deeg D.J.
        Self-reports and general practitioner information on the presence of chronic diseases in community dwelling elderly. A study on the accuracy of patients' self-reports and on determinants of inaccuracy.
        J Clin Epidemiol. 1996; 49: 1407-1417
        • Twisk J.W.R.
        Applied longitudinal data analysis for epidemiology. A practical guide.
        Cambridge University Press, Cambridge2003
        • Song X.
        • Mitnitski A.
        • Rockwood K.
        Prevalence and 10-year outcomes of frailty in older adults in relation to deficit accumulation.
        J Am Geriatr Soc. 2010; 58: 681-687
        • Frosch D.L.
        • Rincon D.
        • Ochoa S.
        • Mangione C.M.
        Activating seniors to improve chronic disease care: results from a pilot intervention study.
        J Am Geriatr Soc. 2010; 58: 1496-1503
        • van Hout H.P.J.
        • Jansen A.P.D.
        • van Marwijk H.W.J.
        • Pronk M.
        • Frijters D.
        • Nijpels G.
        Prevention of adverse health trajectories in a vulnerable elderly population through nurse home visits: a randomized controlled trial [ISRCTN05358495].
        J Gerontol A Biol Sci Med Sci. 2010; 65: 734-742
        • Drubbel I.
        Frailty screening in older patients in primary care using routine care data.
        Utrecht University, Utrecht2014
        • Metzelthin S.F.
        • van Rossum E.
        • de Witte L.P.
        • et al.
        Effectiveness of interdisciplinary primary care approach to reduce disability in community dwelling frail older people: cluster randomised controlled trial.
        BMJ. 2013; 347: f5264
        • Hoogendijk E.O.
        • Muntinga M.E.
        • van Leeuwen K.M.
        • et al.
        Self-perceived met and unmet care needs of frail older adults in primary care.
        Arch Gerontol Geriatr. 2014; 58: 37-42
        • D'Souza S.
        • Guptha S.
        Preventing admission of older people to hospital.
        BMJ. 2013; 346: f3186
        • Rockwood K.
        • Howlett S.
        • Stadnyk K.
        • Carver D.
        • Powell C.
        • Stolee P.
        Responsiveness of goal attainment scaling in a randomized controlled trial of comprehensive geriatric assessment.
        J Clin Epidemiol. 2003; 56: 736-743
        • Hussey M.A.
        • Hughes J.P.
        Design and analysis of stepped wedge cluster randomized trials.
        Contemp Clin Trials. 2007; 28: 182-191
        • Muntinga M.E.
        • van Leeuwen K.M.
        • Schellevis F.G.
        • Nijpels G.
        • Jansen A.P.D.
        From concept to content: assessing the implementation fidelity of a chronic care model for frail, older people who live at home.
        BMC Health Serv Res. 2015; 15: 18
        • Clegg A.
        • Young J.
        • Iliffe S.
        • Olde Rikkert M.
        • Rockwood K.
        Frailty in elderly people.
        Lancet. 2013; 381: 752-762