Frail Elderly

An overall process evaluation plan was developed for this project. This is presented in Table 1. In addition, more detailed evaluation plans for each intervention study were created (see additional files 1, 2 and 3). The modified framework for implementation fidelity was used to define the areas to be measured. These are presented at the first column of Table 1. Steckler et al.'s [13 ] stepwise approach to designing a process evaluation was used as a tool for planning the practical steps in the evaluation process. In accordance with the approach, first a description of the actual program and its theoretical basis, purpose, core inputs, and expected outcomes was made. This description was summarized in a logic model. Separate logic models were created for each of the three intervention studies. As an example, the logic model for the Continuum of care for frail elderly persons, from the emergency ward to living at home intervention project is presented in Table 1.
In the second step, a detailed description of the components of the programs was created. At this stage, each component of the intervention and its intended delivery was described as these were stated in a program plan. Also, the content and delivery of the program for the control group was described. Amount of intervention services and frequency of delivering these services were described in detail. Table 2 presents the delivery process of the Continuum of care for frail elderly persons, from the emergency ward to living at home intervention.
In the third stage, general process questions were developed (second column in Table 3). One to three questions were developed for each fidelity component and potential moderating factor. For instance, subcategories of fidelity are measured through questions: 'Was each of the intervention components implemented as planned?,' 'Were the intervention components implemented as often and for as long as planned?' and 'What proportion of the target group participated in the intervention?.' To measure participant responsiveness, three questions were developed: 'How did the participants become engaged in the intervention services?,' 'How satisfied were the participants with the intervention services?' and 'How did the participants perceive the outcomes and relevance of the intervention?.' After developing the general process questions, more specific questions for each of the intervention projects were developed. These are described in additional files 1, 2 and 3.

The FRESH-screening includes five short questions. The first four questions regarding mobility tiredness, fatigue, risk or fear of falling, and dependence in shopping were extracted from the “Continuum of care for frail elderly people” study questionnaire and were identified as early indicators of change in frailty by the research group. The four questions were as follows: 1) “Do you get tired when taking a short (15–20 min) walk outside?” (positive answers included both “yes,” and “can’t do it”) [25 (link)]; 2) “Have you suffered any general fatigue or tiredness over the last 3 months?” [21 ]. 3) “Have you fallen these last 3 months?” and “Are you afraid of falling?” (positive answers included “yes, a bit,” “yes,” and “yes, very afraid”); and 4) “Do you need assistance in either getting to the store, managing obstacles (such as staircases) to and from the store, or in choosing, paying for, or bringing home groceries?” [26 ]. The fifth question pertained to having had three or more emergency department (ED) visits over the last 12 months, which was considered clinically important by the healthcare service. The total number of healthcare visits was collected for each participant through registers. Subjects were considered to be at risk of frailty by answering “yes” to two or more of these five questions.

The participants were recruited at the emergency wards. The nurse with geriatric competence screened most of the patients during her work shift (daytime, weekdays, approximately 3-4 days per week) to see if they fulfilled the inclusion criteria. If so, the nurse informed them about the study both verbally and in writing. The information included a description of the study, how it would be conducted and what was expected of people who agreed to participate. There were opportunities to ask questions if anything was unclear. It was stressed, both in the verbal and the written information that participation was voluntarily. Of all those invited to participate, 17 were invited by letter, as they had been discharged before the nurse was able to ask them. People who accepted to participate in the study were randomised to intervention or control by using a system of sealed opaque envelopes. All participants signed a written consent form. The study started with a pilot study to test intervention, inclusion/exclusion criteria and logistics. The pilot study comprised the first ten included participants.
A baseline interview and assessment were done within a week of discharge. In some cases it was not possible to do the baseline interview so soon, mostly because the frail elderly person not having enough strength. Follow-up data are collected at 3, 6 and 12 months, see table 1 for description of the objectives, outcome measures and follow ups of the study. On the follow ups, there was also sometimes a delay, owing to the frail elderly person's lack of strength or readmission to hospital. The baseline interviews for the intervention group were done by the multi-professional team as part of their comprehensive geriatric assessment. The baseline interview for the control group and all follow ups for both groups were done by research assistants, who were occupational therapists, nurses or social scientists. The interviews were performed in the participants' home. All interviewers were well trained in interviewing, assessing and observing, according to the guidelines for the different outcome measurements. It was not possible to keep the interviewer blinded to group assignment when doing the follow ups. The reasons for this are threefold: 1) in most cases the participant revealed the assignment unintentionally; 2) some elderly people were not aware that the case manager was part of the intervention and thus did not answer the questions about their experience of receiving the intervention unless the research assistant knew that they were assigned to the intervention; and 3) we assumed there would be less attrition if the elderly person could meet the same research assistant for most of the follow ups.
Meetings are held regularly with all personal in the intervention from one month before starting the inclusion process and throughout the entire intervention period (including the pilot study). In addition, the project leaders for the research and the different care levels, i.e. emergency care, municipal care and primary care, meet regularly during the intervention period.

We performed a focused literature search and consulted with a working group of experienced clinicians, researchers, and patient partners to collate a list of frailty-related terms. This approach was adapted from Urquhart et al.’s development of a rule to identify frailty in administrative health databases [25 (link)]. The aim was to construct a list of terms or phrases that would commonly be used by providers to describe patients living with frailty.
The focused literature review involved an initial scan of PubMed using combinations of the following terms: “frail elderly”, “frailty”, “identification”, “definition”, “database”, and “health data”. We were particularly interested in studies that have used key-term searching to identify frailty in the free text of other healthcare datasets. We considered a variety of study types, including systematic reviews and other evidence syntheses, clinical guidelines, retrospective studies of healthcare or administrative databases, and studies that have developed or validated frailty assessment tools. Search results were supplemented by articles recommended by the research team and a hand search of reference lists of selected articles.
Relevant findings from the literature search were summarized. From each included study, we extracted terms related to the identification or assessment of frailty, including but not limited to signs and symptoms, comorbidities, disabilities, and related clinical syndromes.
To ensure the content validity of our selection, the preliminary list of frailty-related terms was then shared for feedback with a working group of clinicians (n = 4), researchers (n = 4) and a patient partner (n = 1) who are knowledgeable about LTC, primary care and frailty, each bringing diverse perspectives on these topics (see corresponding section in Supplemental Methods). Through iterative discussions and revisions, a version of the list of frailty terms was finalized for a key-term search of the eConsult text. The list was organized by grouping terms into overarching topic categories.