Formulation of and adherence to a care plan for potentially frail community-dwelling older people by practice nurses in the Netherlands

Background: In the Netherlands, p ractice nurses within general practices increasingly deliver proactive care to older people. As part of a home visitation programme, they assess older people’s health status during a home visit, followed by formulating a care plan and monitoring follow-up care. Insight into the latter two steps is limited, whereas previous research shows signs of inadequate follow-up, threatening the achievement of optimal patient outcomes. The objectives of the current study are to investigate practice nurses’ actions and views regarding (1) the formulation of a care plan for potentially frail community-dwelling older people following a comprehensive geriatric assessment during a home visit and (2) their adherence to the care plan and monitoring during follow-up of older people in whom health and/or well-being problems have been detected. Methods: A cross-sectional mixed-model study was conducted. Results of the comprehensive geriatric assessment were compared to the care plans to reveal the percentage of problems included. Semi-structured interviews were performed with 12 practice nurses who visited older people at home. Per practice nurse, care plans of 10 older people (total n = 120) were purposefully selected and discussed to identify reasons for not registering problems in the care plan and to determine whether and how problems were monitored. Results: Of the problems identified through comprehensive geriatric assessment, 27.8% ( n = 275) were included in a care plan of which 62.9% ( n = 173) were addressed using follow-up actions. Patient-related and problem-specific factors influenced the formulation of care plans. Insufficient time challenged practice nurses in monitoring older people over time. Conclusions: The formulation of care plans and monitoring older people over time offers room for improvement. Once problems are included into the plans, practice nurses mostly adhere to the care plans.