Designing a protocol for innovative projects of care and support targeting community dwelling frail elderly

Introduction and background : The Belgian national social health insurance system (INAMI/RIZIV) will finance alternative forms of care, in order to prevent institutionalization of the community-dwelling frail elderly. Bottom-up projects will receive grants if they propose innovative forms of care and support of care provided in a patient-centred and concerted way, if they target community dwelling frail elderly people with complex care needs and their informal caregivers and finally, if they prevent institutionalization of frail elderly. This paper presents the design of a protocol for the scientific evaluation of these projects. Its aim is to provide evidence to assist RIZIV/INAMI and other public authorities in future long term innovative care programs decision making. Methods : The general design has been driven by complex intervention evaluation methodologies, and performed by a multidisciplinary team, including nurses (MPH), GPs, epidemiologists, geriatricians, economists and sociologists. Three types of approaches were used: (1) a theory driven approach, through a literature review for model design; (2) a grounded approach, through candidate projects review and (3) a pragmatic approach for data collection, including tools chosen by the INAMI/RIZIV in previous projects. Results : Given the heterogeneity of the projects to be tested and their complex nature, 4 key objectives, related to 4 types of evaluations, are proposed. 1. Modelling the project components as part of a care system, to clarify mechanisms through which the projects could influence outcomes for frail elderly; 2. Performing an process implementation evaluation to identify threats and opportunities; 3. Performing an evaluation of outcomes for frail elderly and informal caregivers; 4.Performing an economic evaluation to assess various dimensions of the total cost of home maintaining when and the efficiency for the different types of projects. The Chronic Care model (Wagner et al., 1996) is used for organizational analysis, Van Bilsen’s model (Van Bilsen, 2006) for the determinants of service utilization and the International Classification of Functioning disabilities and health (ICF) model for the description of the health and functional status of the frail elderly. A primary qualitative analysis, using the chronic care model and based on the submission files of the candidate (i.e. not yet accepted) projects (n=132), shows a highly heterogeneous group of projects. The main group of projects intends to focus on coordination of care (n=49, 37%), while other focuses on specific services (ergotherapy, psychological help ...). Assessing the health and needs, quality of life, burden of the main caregivers and economic evaluation is performed through validated tools (i.e. BelRAI, WHO-QoL-8, Zarit-12 item). Conclusion : As a result of the process of designing this evaluation protocol for complex interventions, the 4-step evaluation process should provide an exhaustive insight of the projects’ process, functioning and results in terms of efficacy. Influence on the older peoples’ health and how their needs have been met will be measured through regularly collected data. The future should give us a more precise view on the adequacy of this process.