Table 3

Key features of the proposed intervention in elderly care

Key features of the Proposed Intervention in Elderly Care

Objectives:

• Improve care for older persons with complex and multidimensional chronic conditions

• Prevent unwanted institutionalization and unnecessary use of services

Clinical, collaborative and organizational means:

Strengthen primary care

• Maintain the PCP as the main medical practitioner

• Integrate health professionals into a multidisciplinary team

• Introduce a case manager collaborating with PCPs

• No translocation to secondary care

Coordinate primary and secondary care

• Better communication

• Access to geriatric expertise for PCP (a community-based geriatrician)

• Direct access to hospitalization

No change in funding mechanisms

Vedel et al. Implementation Science 2009 4:21   doi:10.1186/1748-5908-4-21