Cooperation, laws and regulations - Elderly, chronically ill and people with physical disabilities

Cooperation, laws and regulations - Elderly, chronically ill and people with physical disabilities
Care for the elderly and chronically ill almost always requires cooperation. After all, different disciplines are almost always involved in healthcare for a longer period of time. Care standards and guidelines offer the professionals a handle, but it is up to the care providers in every neighborhood, municipality, region to set up partnerships and make agreements.

Cooperation, laws and regulations


Care for the elderly and chronically ill almost always requires cooperation. After all, different disciplines are almost always involved in healthcare for a longer period of time. Care standards and guidelines offer the professionals a handle, but it is up to the care providers in every neighborhood, municipality, region to set up partnerships and make agreements.


Making the practice senior proof

View whether your practice or pharmacy is senior proof in terms of accessibility, design and organization. The dentist organization KNMT has drawn up a checklist for dental practices. This list is largely useful for other primary care organizations. Discuss in your team which improvements are possible.


Collaboration / Care programs and chain care

There are local and regional primary care groups that provide and coordinate complete care for a patient category. For example, they offer care for people with type 2 diabetes, (risk of) cardiovascular disease, COPD, depression and anxiety disorders. Agreements have been made about who (which discipline) offers which care. Local or regional agreements have also been made about the referral criteria to a hospital.


It is more difficult when a patient has different (chronic) diseases and / or risk factors for different health problems. About a quarter of the elderly will experience this vulnerability in the coming years.



Vulnerable elderly

Vulnerable elderly people live in very different housing settings: at home, care or nursing home, care institution for first-line care or geriatric rehabilitation ( Care for these vulnerable elderly requires extra attention from all involved and mutual coordination. Some regions have a care program for vulnerable older people. Practice supporters for the elderly / geriatrics play an important role in this. To begin with, they determine which patients in practice belong to the group of vulnerable elderly. That can be done in different ways. They then examine the needs of the elderly and organize and coordinate care. Good care cannot succeed without a good network. In the meantime, this must be built up or strengthened (Vilans 2014). Incidentally, not all elderly people appreciate receiving an unsolicited invitation to visit a doctor or practice assistant. Proper explanation and meeting needs can reduce the feeling of patronizing.


Collaboration with specialist geriatric medicine

The biggest bottleneck for GPs in long-term care is the lack of time for care for the vulnerable patient and insufficient availability (and flexible financing) of an elderly care medicine specialist to set up good cooperation. Measures were taken in 2016 to facilitate financing.


Collaboration in oral care for vulnerable elderly

Nationally, projects are being implemented to support oral care by and for the elderly. Both with elderly people living at home and with elderly people in care institutions (Don't forget the mouth and Keep the older mouth healthy Cleaning instruction cards have been developed for nursing staff in care and nursing homes. Some dental practices offer training. If treatment is not possible in primary care, the patient may be referred to a center for special dentistry. In a single region, the dentist can treat patients at home.



Facilities, neighborhood team, social map

There are many facilities for the elderly, chronically ill and people with disabilities. Think of (digital and physical) facilities such as control assistance, shopping services, DIY services, meal services, neighborhood meals, transport arrangements, buddy projects.


These facilities and the local social map, including the neighborhood team, are not further elaborated here, because they differ greatly per municipality.


Polypharmacy in the elderly

Adverse effects of polypharmacy in the elderly must be prevented as far as possible. It has therefore been agreed that people aged 65 years and older with polypharmacy should check whether they are at extra risk of unwanted consequences (Multidisciplinary guideline Polypharmacy in the elderly, NHG 2012; With one additional risk factor, it is desirable to evaluate the medication every year. Attention is also paid to the actual use of medicines, the necessity of each medicine and side effects.


This medication assessment includes: an assessment of pharmacotherapy by patient, (nursing) doctor and (family) pharmacist, based on a step-by-step plan. There are various methods for this: the STRIP (Systematic Tool to Reduce Inappropriate Prescribing), a combination of step-by-step plans including the POM (Prescribing Optimization Method). The criteria for medication assessment are set out in the following box.


Criteria for annual medication assessment in the elderly with polypharmacy

The assessment applies to:

  • Patients who are 65 years or older and use five or more drugs chronically, and
  • Have at least one of the following risk factors:

- Impaired renal function (GFR <50 ml / min);

- Decreased cognition (dementia) or indications for memory disorders and other cognitive disorders;

- Increased risk of falling (fallen one or more times in the previous twelve months);

- Signals of impaired therapy compliance;

- Not living independently (care home or nursing home);

- Unplanned hospitalization.


Whatever step-by-step plan is used for medication assessment, it always contains a number of essential elements.



Step-by-step plan for medication assessment

   Step  Explanation
 1. View and check the medication list In patients with polypharmacy, the medication overview is often incorrect or not; patients often do not have an up-to-date list themselves, do not swallow all the medication on the list and, moreover, often use freely available medicines
 2. Ask which medicines are actually used, including self-care medicines

- Check what the patient actually uses, which one from the list and which others; ask the patient to take all medication he uses (including self-care products, herbal or homeopathic remedies and vitamins) to the conversation; prepare a current and complete list of drug use

- Pay attention to possible interactions, also between prescribed medicines and self-care products

 3. Ask for side effects and assess kidney function

- Many patients do not know which side effects may occur; complaints, such as drowsiness, sleep disorders, dizziness, falling and constipation, are by no means always associated with medication; it is therefore important to ask specifically about this

- Older users have side effects much more often than younger users of the same medicine; the worse the kidney function, the greater the chance of side effects from drugs (excreted through the kidney)

- Side effects have a lot of influence on the patient and are an important reason to use the medicine less often than prescribed or to leave it at all

 4. Assess whether drugs can be deleted or added, or whether the frequency or dosage needs to be adjusted

- Often a patient uses medication that is no longer needed or that is contraindicated in the elderly; the STOPP criteria list (Screening Tool of Older Person's Prescriptions) indicates which resources can be stopped better; that does not mean that the doctor cannot prescribe them, but he will have to look carefully if there is no alternative; if there is none, it is wise to start with a low dose and regularly check for side effects

- The other way round also occurs: an agent that is indicated is not prescribed by mistake (opioid laxative, beta-blocker after heart attack, gastric protector with NSAID)

- The more often a medicine has to be taken in one day, the lower the therapy compliance is: if taken once a day, therapy compliance is approximately 80%, if taken 4x once a day approximately 50%; a complicated intake schedule also makes good use difficult; that may be a reason to adjust the dosing frequency by, for example, prescribing a sustained-release tablet or a combination preparation; half tablets are less practical


Make new agreements about medication use

Adjust the medication overview

- Make new appointments in consultation with the patient; take into account the objections, possibilities and preferences of the patient

- Record the agreements (medication, frequency, dosage, form) in a new medication overview

 6. Make agreements about monitoring medication use Record who, when and how in the near future will monitor how the use of medication is going


Primary care for people in a nursing home or other care institution

General practitioner care in care homes and small-scale housing types

Many residents cannot easily come to the practice. That is why GP practices often arrange an appointment consultation on location. That prevents too many visitors. Good agreements are needed to ensure that such an appointment consultation runs smoothly. Agreements about:

  • Who can arrange a consultation / visit: the patient, the caregiver, the coordinator / the department head, and which data must then be available;
  • Who receives the request for the appointment: the practice assistant or the practice assistant;
  • Who is present during the office hours for support: the (contact) caregiver of the patient or the nurse of the care institution, the practice assistant or the practice assistant of the general practitioner.


Practice assistants must ask for a complaint when asking for a visit as with a patient living at home. They would do well to ask the patient himself on the telephone, even if the caregiver calls. And they ask if more visits are requested, so that they can be combined.



Pharmaceutical care in care homes and small-scale housing types

It works best, with the least chance of communication problems and errors, when pharmaceutical care is in the hands of one pharmacist. Agreements must then be made with the health care insurer and the coordinator of family care, because that cannot be simply imposed.


Oral care in care and nursing homes and small-scale housing types

In recent years, more attention has been paid to (supporting) oral care in care and nursing homes and small-scale forms of living. Materials have been developed, such as cleaning instruction cards, and training projects have been set up. Not all nursing homes provide care by their dentists and dental hygienists to their residents and by no means all dental care rooms in nursing homes offer sufficient facilities for good care.


Innovative projects

We give some examples of innovations in practice.



Neighborhood nurse

There are projects in which a district nurse visits a patient before he is released from the hospital. After returning home, she keeps in touch with the patient. This reduces the chance of medication problems and medication errors at home. This reduces the number of readmissions and even deaths after discharge from the hospital.


Primary residence

If a patient cannot go home after a hospital stay due to lack of care or 24-hour supervision, the patient can be admitted to a nursing home or general practitioner's hospital (a hospital department with general practitioner care) for first-line residence. This is also possible if a patient living at home needs temporary 24-hour supervision or care without the need for hospitalization. The general practitioner is responsible for the regular general practitioner care there, unless he transfers the care to a geriatric specialist. There is a subsidy scheme for this up to 2017; from 2017 this falls under the health insurance law.


There are agencies in different regions that arrange admission to a primary care center. For example, a transfer department of a hospital and an acute service (of primary care organizations and health insurer).


Eyes and ears

Pharmacists have developed various projects to collect and share information with other professionals. Assistants in the pharmacy may notice that a patient has difficulty understanding the medication instruction, or that he is anxious or lonely. They can pass this information on to the neighborhood team. For this, they must of course have the consent of the patient (project Pharmacy and neighborhood team



Regulations and legislation

The elderly and the chronically ill may have to deal with many different regulations and laws. Nursing at home has been included in the basic package since 2015, but household support is covered by the Social Support Act. The patient must submit a request for this to the municipality, as well as requests for transport, medical aids and adjustments. For this purpose, district teams and / or a Social Support Desk have been set up in most municipalities.