Table 1 Description of the U-PROFIT 1.0 and U-PROFIT 2.0 Program

1. Frailty assessment.

• The level of frailty in patients at risk were selected by U-PRIM and further explored with the Groningen Frailty Indicator questionnaire (GFI) which was send by a practice nurse. The U-PRIM software application is an electronic monitoring system aiming at identification of older patients at increased risk of frailty in routine health care data. The software is based on periodic screening for relevant risk factors in the EMRs of the general practice. U-PRIM screens for three core risk factors in patients aged 60 years or older. These are also the eligibility criteria of the U-PROFIT trial as described earlier (multimorbidity, polypharmacy and a care gap). The GFI, a 15-item validated questionnaire that assesses frailty from a functional ADL/ IADL perspective on four domains: physical, cognitive, social and psychological. We chose a score of 4 or higher as the relevant cut-off for the selection of patients that should be visited for a comprehensive geriatric assessment.

2. Comprehensive Geriatric Assessment at home (CGA)

• A CGA at home is conducted by a registered practice nurse. During this home visit, the practice nurse focuses on patients’ health problems and needs in a structured manner based on the outcome of the frailty assessment

3. Tailor-made care plan

• In collaboration with the GP, the practice nurse will prepare a tailor-made care plan based on the outcome of step 2. This tailor-made care plan consists of interventions derived from evidence-based care plans developed by the research team, practice nu

4. Monitoring

• Care coordination and follow-up were provided by the practice nurse.

1. Frailty assessment.

• The level of frailty in patients at risk were selected by U-PRIM and further explored with the GFI which was send by a practice nurse.

2. Comprehensive Geriatric Assessment at home (CGA)

• A CGA at home is conducted by a registered practice nurse or district nurse. During this home visit, the practice nurse or district nurse focuses on patients’ health problems and needs in a structured manner based on the outcome of the frailty assessment

3. Tailor-made care plan

• In collaboration with the GP, district nursing and social work, the practice nurse or district nurse, will prepare a tailor-made care plan based on the outcome of step 2. This tailor-made care plan consists of interventions derived from evidence-based care plans developed by the research team, practice nu

4. Monitoring

• Care coordination and follow-up were provided by either the district nurse, practice nurse or social worker which was based on the needs of the patient.

U-PRIM U-CARE