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.