Integrated Care for Older Adults Improves Perceived Quality of Care: Results of a Randomized Controlled Trial of Embrace
Integrated Care for Older Adults Improves Perceived Quality of Care: Results of a Randomized Controlled Trial of Embrace
Ronald J. Uittenbroek
Hubertus P. H. Kremer 0
Sophie L. W. Spoorenberg
Sijmen A. Reijneveld 1
Klaske Wynia 0 1
0 Department of Neurology, University Medical Center Groningen, University of Groningen , Groningen , The Netherlands
1 Department of Health Sciences, Community and Occupational Medicine, University Medical Center Groningen, University of Groningen , Groningen , The Netherlands
BACKGROUND: All community-living older adults might benefit from integrated care, but evidence is lacking on the effectiveness of such services for perceived quality of care. OBJECTIVE: To examine the impact of Embrace, a community-based integrated primary care service, on perceived quality of care. DESIGN: Stratified randomized controlled trial. PARTICIPANTS: Integrated care and support according to the BEmbrace^ model was provided by 15 general practitioners in the Netherlands. Based on self-reported levels of case complexity and frailty, a total of 1456 communityliving older adults were stratified into non-diseasespecific risk profiles (BRobust,^ BFrail,^ and BComplex care needs^), and randomized to Embrace or control groups. INTERVENTION: Embrace provides integrated, personcentered primary care and support to all older adults living in the community, with intensity of care dependent on risk profile. MEASUREMENTS: Primary outcome was quality of care as reported by older adults on the Patient Assessment of Integrated Elderly Care (PAIEC). Effects were assessed using mixed model techniques for the total sample and per risk profile. Professionals' perceived level of implementation of integrated care was evaluated within the Embrace condition using the Assessment of Integrated Elderly Care. KEY RESULTS: Older adults in the Embrace group reported a higher level of perceived quality of care than those in the control group (B = 0.33, 95 % CI = 0.15-0.51, ES d = 0.19). The advantages of Embrace were most evident in the BFrail^ and BComplex care needs^ risk profiles. We found no significant advantages for the BRobust^ risk profile. Participating professionals reported a significant increase in the perceived level of implementation of integrated care (ES r = 0.71). CONCLUSIONS: This study shows that providing a population-based integrated care service to communityliving older adults improved the quality of care as perceived by older adults and participating professionals.
One of the main challenges for today’s healthcare systems is
organizing high-quality, comprehensive, person-centered,
integrated care and support for older adults.1–3 Addressing these
challenges requires comprehensive, and thus complex,
interventions in community-based healthcare systems.4–6
However, evidence is still lacking regarding the effectiveness of such
interventions on patient outcomes and quality of care as
perceived by older adults.7,8
A promising approach to delivering age-specific long-term
care and support lies in integrated care services. The Chronic
Care Model (CCM)9 is a well-known framework that can be
used to develop such services. The CCM integrates community
social care and healthcare services, and has four interdependent
key elements: self-management support, delivery system
design, decision support, and clinical information systems. An
example of a CCM-based integrated care service is the
BGuided Care" model for multimorbid older adults.10 Within
Guided Care, a physician–nurse primary care team provides
care for the most complex patients, with the aim of increasing
both quality of care and quality of life while lowering costs.
Studies on this service have shown encouraging effects on
perceptions of quality of care among older adults.11 However,
as is typical of such initiatives, this service targets only those
already in need of care. It is well known that the health status of
older adults can change quickly, taking a sudden turn for the
worse.4 Moreover, preventive and proactive care may help to
delay declining health status among older adults.12–16
Therefore, integrated care models could be even more
effective if they targeted the general population of older adults.
On the other hand, delivering the same care intensity to all
older adults is neither needed nor sustainable.17 Thus a more
practical solution may be in combining integrated care models
with population health management models. These models
can help stratify a population of community-living older adults
into risk profiles with corresponding levels of care and support
that are non-disease- and non-service-specific.18
Embrace (in Dutch: BSamenOud^)19 is an integrated care
service designed for all community-living older adults, which
combines the CCM with risk profiles based on a population
health management model, the Kaiser Permanente Triangle.20
In the Embrace model, participating older adults are stratified
into the risk profiles based on self-reported levels of Bcase
complexity^21 and level of Bfrailty,^22 and care and support
are then offered by a multidisciplinary Elderly Care Team,
with intensity determined by individual risk profiles. Embrace
aims to integrate health and social services with preventive
care and support, and was developed to improve patient health
outcomes as well as quality of care, service use, and cost.
The aim of the present study was to assess the effects of
Embrace on the quality of care as perceived by
communityliving older adults and participating professionals.
We performed a randomized controlled trial (RCT) from
January 2012 through March 2013, in which older adult
participants were stratified into risk profiles and equally allocated to
intervention and control groups, as reported previously.19
Alongside the RCT, the perceived Blevel of implementation
of integrated elderly care^ of participating professionals was
evaluated within the intervention arm. The Medical Ethical
Committee of the University Medical Center Groningen
assessed our study proposal and concluded that their approval
was not required (Reference METc2011.108). The study was
performed in accordance with the tenets of the Declaration of
We calculated the sample size for participants based on a
clinically relevant change in the self-reported health status
visual analogue scale as measured with the visual analogue
scale of the EuroQol-5D (EQ-5D-VAS).24 We needed 1062
older adults to detect a six-point difference on the EQ-5D-VAS
with a standard deviation of 14 points, power of 80 %, and
two-sided p value of 0.05 in the smallest risk profile (BFrail^).
With an estimated loss to follow-up of 30 % and 30 %
nonresponse, 2178 older adults needed to be invited. With an
average of 200 enlisted older adults per general practitioner
(GP) practice (also referred to as family physicians or primary
care physicians), 11 GP practices were required.
Participants and Procedure
First, we invited all 24 GPs in three municipalities in the
province of Groningen, the Netherlands, to participate. After
15 GPs consented to participate, we stopped recruitment.
Participating GPs were evenly distributed over the three
municipalities. This included six GPs who were working as
solo GPs and nine GPs who were part of a partnership or group
practice. This distribution of practice types is comparable to
that in the rest of the Netherlands.25 Next, we invited all adults
aged 75 years and over from these 15 GP practices. Exclusion
criteria were long-term admission to a nursing home (the
equivalent of a US skilled nursing facility), involvement in a
comparable integrated care service, or participation in another
Eligible older adults received a letter from their GP
with general information about the study. Once their
written consent was provided, these adults completed
self-report questionnaires and answered questions
regarding demographic and health-related characteristics, both
at baseline and after 12 months of follow-up.
Participating professionals were asked to complete a questionnaire
both at baseline and 12-month follow-up.
Stratified Randomization and Blinding
Participating older adults were stratified into three risk
profiles based on their responses on the questionnaires
regarding case complexity (INTERMED for the Elderly,
self-assessment, INTERMED-E-SA)21 and frailty
(Groningen Frailty Indicator, GFI).22 The risk profiles were
as follows: BRobust^ (INTERMED-E-SA score < 16 and
GFI score < 5), BFrail^ (INTERMED-E-SA score < 16 and
GFI score ≥ 5), and BComplex care needs^
(INTERMEDE-SA score ≥ 16, irrespective of GFI score). After
stratification, we performed a concealed and computerized
balanced allocation procedure to achieve equal
distribution between the intervention and control groups with
regard to participants’ demographic and health-related
Due to the study design, Elderly Care Team members knew
which participants were assigned to Embrace. The
participating older adults were informed in writing as to whether they
were assigned to an intervention or a control group. For
practical reasons, the data manager was not blinded;
researchers, however, were masked until analysis.
For Embrace, a GP-led Elderly Care Team was assembled
within each participating GP practice, in which the GP
remained responsible for writing prescriptions and
implementing the interventions. The Elderly Care Team
additionally consisted of an elderly care physician (i.e., a nursing
home physician), a community nurse, and a social worker. All
Elderly Care Team members completed a training program.
The initial training for the GPs (3 days in total) focused on
team and population management and on essential themes
such as multimorbidity and polypharmacy. Social workers
and district nurses received specific training in areas such as
case management and shared decision making during an 8-day
initial training program. All members of the Elderly Care
Teams received monthly on-the-job coaching during their
The Elderly Care Team provided older adults with
comprehensive, patient-centered, proactive, and preventive care and
support. Members met monthly for consultation at the
participating GP practice. The intensity and focus of care and
support at the patient level differed by risk profile in terms of
number of contacts, main focus, health-related vs. social
problems, and individual vs. group approach. Older adults within
the BFrail^ and BComplex care needs^ profiles received
individual care and support from a case manager, a social worker,
and community nurse, respectively. They visited these older
adults at home once or twice a month, and focused specifically
on problems experienced by older adults, i.e., emotional and
exercise tolerance functions.26
Elderly Care Team monitoring of older adults within the
BRobust^ profile consisted in reviewing their medical files,
medications, and self-reported levels of frailty and case
complexity once a year. Participating BRobust^ older adults were
encouraged to contact the Elderly Care Team if their health or
life situation changed. They received a questionnaire on
changes in their health or life situation and directions for
follow-up. The Elderly Care Team acted proactively in cases
of suspected deterioration in health status (e.g., increased
forgetfulness, sudden loss of weight) or an imminent loss of
support from the informal network (e.g., an overburdened
caregiver) for older adults who received case management.
Finally, all participating older adults were offered a
selfmanagement support and prevention program that included,
for example, community meetings and newsletters
emphasizing the need for prevention and healthy lifestyles while
maintaining self-management abilities. See Online Supplementary
Table S1 for additional details on intensity, duration, and cost
per risk profile.
Care as Usual
The control group received usual care as provided by their GP
and the local health and social care organizations. In the
Netherlands, municipalities are responsible for social care
and health promotion, which is government (tax)-funded.
Basic healthcare insurance is obligatory, and covers almost
all primary and secondary healthcare. The GP acts as
gatekeeper for specialized medical care. GP visit rates increases
with age, from four visits per year at ages 45–64, to ten visits
annually at ages 75 years and older.27
The primary outcome for this study was quality of care as
reported by older adults on the Patient Assessment of
Integrated Elderly Care (PAIEC) scale (see Online Appendix).28 The
PAIEC is a modified version of the Patient Assessment of
Chronic Illness Care (PACIC),29 and consists of 20 items
divided into three subscales: BPatient activation and
contextual information,^ BGoal-setting and
problemsolving,^ and BCoordination and follow-up.^ Each item was
scored on a five-point scale ranging from 1 (never) to 5
(always), or the response option Bdoes not apply.^ The
response option Bdoes not apply^ and missing values were
recoded to Bnever^ to gain a more realistic estimate of the
integrated care received and its intensity. Next, we calculated
index scores by subtracting the minimum scale score from the
raw scale score, dividing this by the scale score range, and then
multiplying by 100, resulting in scores ranging from 0 to 100,
with higher scores reflecting better perceived quality of care.
We then normalized the skewed PAIEC distribution by a
power (square root) transformation (√[PAIEC index scores
The secondary outcome for this study was the Blevel of
implementation of integrated elderly care^ as reported by the
professionals on the Assessment of Integrated Elderly Care
(AIEC) scale. The AIEC is a modified version of the validated
Assessment of Chronic Illness Care (ACIC version 3.5),
which assesses whether the care and support provided is in
accordance with the Chronic Care Model.32,33 The AIEC
consists of 34 items divided into 7 subscales: BHealthcare
organization,^ BCommunity linkages,^ BSelf-management
support,^ BDelivery system design,^ BDecision support,^
BClinical information systems,^ and BIntegration of CCM
elements.^ Each item was scored on a scale of 0 to 11, and
total and subscale sum scores were calculated after recoding
missing items into score B0,^ and converted into index scores
), with higher scores reflecting a higher Blevel of
implementation of integrated elderly care.^ This questionnaire
was translated following a forward–backward procedure,34
and then modified for the care offered–in other words,
Bchronic care^ was converted into Bcare and support for older
We first constructed a flow diagram and described baseline
characteristics of participating older adults at the overall
sample level and per risk profile. We tested differences between
groups using the t test for continuous variables, the Mann–
Whitney U test for ordinal and not normally distributed
continuous variables, and the Chi-square test for categorical
We next assessed the effects of Embrace on quality of care
in terms of regression coefficients (B) with 95 % confidence
intervals (CI), using multi-level analyses, with older adults as
lower level and GP practices as higher level, adjusted for age
and gender. We used an intention-to-treat (ITT) analysis, with
the last observation carried forward, followed by a complete
case analysis–both at the total sample and risk profile levels. In
addition, we assessed effect sizes by calculating Cohen’s d for
regression coefficients, considering an effect size ≥ 0.2 to be
Finally, we assessed changes in the level of implementation
of integrated elderly care from the perspective of the Elderly
Care Team members. We combined the team members’ scores
with the aggregated total and subscale scores, and then
assessed differences between pre-test and post-test scores
using the Wilcoxon signed-rank test. We assessed effect sizes
by calculating the nonparametric effect size r, considering an
effect size ≥ 0.1 to be clinically relevant.36,37 We conducted all
statistical analyses using SPSS (IBM SPSS Statistics for
Windows, version 22, 2013; IBM Corp., Armonk, NY, USA).
Figure 1 shows the flow of older adults through the study. In
total, 1456 of the 2988 eligible older adults were included in
the ITT analyses. Women, the oldest older adults, and older
adults who lived in rural areas declined participation more
frequently (all p < 0.01). We found no between-group
differences in loss to follow-up for either the total sample or risk
profiles. Older adults lost to follow-up (n = 325, 22 %) were
significantly (p < 0.01) older and frailer, had more complex
care needs and a lower health status, and received home care
Table 1 shows the baseline characteristics of the 1456
participating older adults. We found no statistically significant
differences between the Embrace and control groups, with the
exception of Bhome help received during the past year^ in the
risk profile BComplex care needs^ (p = 0.04).
Primary Outcome: Perceived Quality of Care
Complex care needs
SD = standard deviation, IQR = interquartile range
Low education: primary school, low vocational training, or less
Low household income:eew < €1351 per month
IM-E-SA = Intermed Elderly Self-assessment, GFI = Groningen Frailty Indicator, EQ-5D = EuroQol health-related quality of life, VAS = visual analogue
* Indicates significant differences between groups (p = 0.04)
(small to medium effect sizes). PAIEC scores for the risk
profile BComplex care needs^ differed significantly for the
total scale score and the subscale BActivation,^ with both
indicating clinically relevant differences (small effect sizes),
while no significant advantages were found for the subscales
BGoal-setting and problem-solving^ and BCoordination and
follow-up.^ Complete case analyses confirmed ITT findings
(not shown). Differences between GP practices were trivial.
Secondary Outcome: Perceived Level of Implementation of Integrated Elderly Care
The 30 professionals, 12 of the 14 general practitioners, both
elderly care physicians, 8 of the 9 district nurses, and 4 of the 5
social workers completed 49 (out of 56: 78.5 % response rate)
AIEC questionnaires at baseline and follow-up. They reported
that the average Blevel of implementation of integrated elderly
care^ at baseline was Bbasic^ and, after 12 months,
Breasonably good,^ indicating clinically relevant
improvement (Table 3).
Our study results show that integrated care following the
model improved the quality of care as
perceived by community-living older adults and
participating professionals. Advantages in perceived quality of
integrated care were most evident for older adults
receiving case management and were most prominent for
older adults in the risk profile BFrail.^ This may imply a
positive effect from integrated care for older adults even
when they are only Bat risk^ for poor health outcomes22
or for increasing case complexity,21 with no immediate
need for professional care. Therefore, offering integrated
care services should be considered for all older adults,
particularly considering that proactive preventive care
and support could be increasingly effective for their
health outcomes in the longer run.12,14,16
We found no significant advantages from Embrace for
BRobust^ older adults, or for either BGoal-setting and
problem-solving^ or BCoordination and follow-up^ for the risk
profile BComplex care needs.^ For these risk profiles, the
differences between the Embrace and control groups may have
been too small to detect. Older adults in the BRobust^ profile
of the Embrace group were offered a relatively low-intensity
level of care and support, that is, a Bself-management support
and prevention^ program, including community meetings,
which were attended by about 25 % of these older adults.
Furthermore, older adults were asked to evaluate the quality of
care they received from all professionals, including those who
T0 (Baseline) T1 (Follow-up) Change
Mean (SD) Mean (SD) Mean (SD)
T0 (Baseline) T1 (Follow-up) Change
Mean (SD) Mean (SD) Mean (SD)
*Transformed scores are the square root of index scores
PAIEC = Patient Assessment of Integrated Elderly Care, B = unstandardized regression coefficient, CI = confidence interval
ES = effect size d; thresholds: < 0.2 trivial, ≥ 0.2–0.5 small, ≥ 0.5–0.8 medium, ≥ 0.8 large
were not part of Embrace. This may have diluted the effects of
Elderly Care Team
members reported that the Blevels of
support for integrated elderly care^ improved from Bbasic^ to
Breasonably good^ after 12 months. This may be due to the
intensive training and coaching that they received before and
during the intervention period.38 However, it also indicates
room for improvement towards a goal of Bfully developed
integrated elderly care.^
Strengths of this study include its rigorous design, i.e., a
randomized controlled trial with balanced allocation,39 and its
large community-based sample. Another strength was the
stratification of the population into risk profiles40 using two
non-disease or service-specific identifiers (frailty and case
which takes into account the aims of
person-centered and integrated care.3 Although new and still
in the process of validation,41 the measurement instruments
used were the best available for classifying older adults into
non-disease-specific risk profiles18 and for examining the
quality of care and level of implementation of integrated care
from the complementary perspectives of both older adults and
Some (potential) limitations need to be addressed as well.
First, given the differences between participants and
nonparticipants at a 49 % participation rate, generalization of our
findings requires further investigation. Second, we randomized
participating older adults within the GP practices. This may
have led to some contamination of the control group via the
members of the Elderly Care Team, who received extensive
training and were unblinded, causing some underestimation of
AIEC = Assessment of Integrated Elderly Care; scores: 0–24, limited support for integrated elderly care; 25–49, basic support for integrated elderly
care; 50–74, reasonably good support for integrated elderly care; ≥75, fully developed integrated elderly care
*Wilcoxon signed-rank test
ES = effect size r; thresholds: < 0.1 trivial, ≥ 0.1–0.3 small, ≥ 0.3–0.5 medium, ≥ 0.5 large
the effects of Embrace. Third, older adults in the control groups
were not blinded, which might have led to response bias.
Finally, we had no control group for the professionals.
Participating professionals may have responded in socially desirable
ways, leading to some overestimation of the effects.
Embrace is one of the first services with the aim of providing
person-centered and integrated care to all community-living older
adults. It was built on previous research regarding preventive and
proactive care, and combines the well-known Chronic Care
Model and the Kaiser Permanente Triangle. Our study showed
that such a service can have positive effects on perceived quality
of care. The effects we found were small to medium, and were
most evident for older adults receiving case management. These
results may have implications for policy, practice, and research.
First, our findings could support further development,
integration, and funding of integrated care services for all older
adults. Given the pivotal role of the Elderly Care Team,
Embrace will be of particular value in healthcare systems that aim
to strengthen primary care. Moreover, our findings can aid the
further development of models such as patient-centered medical
homes.44 Second, our findings need to be confirmed in other
settings to assess their generalizability.45 Third, such evaluation
could comprise other, more technical aspects of quality of care,
including whether specific care processes were performed (e.g.,
vaccinations, management of specific disorders).46 Finally, the
effects of Embrace on participating older adults’ health
outcomes, their use of services, and costs must be assessed as well.
Acknowledgments: We would like to thank the participating older
adults and healthcare professionals from the 15 GP practices, the
healthcare organization BZorggroep Meander,^ and the welfare
organization BTinten welzijnsgroep,^ specifically Mr. C.J. Ronde, BSc,
without whom this study could not have been carried out. In addition,
we would like to thank Mr. R.E. Stewart, PhD, for statistical support.
Corresponding Author: Ronald J. Uittenbroek, MSc; Department of
Health Sciences, Community and Occupational Medicine University
Medical Center Groningen, University of Groningen, P.O. BOX 196 9700
AD Groningen, The Netherlands (e-mail: ).
Compliance with ethical standards:
Funding: This study was part of the Dutch National Care for the
Elderly Program and funded by The Netherlands Organization for
Health Research (ZonMw), file number 314010201, and the Dutch
Healthcare Authority (NZA), file number 300-1021. ZonMw and NZA
had no role in study design, data collection, data analysis, data
interpretation, writing of the manuscript, or the decision to submit the
manuscript for publication.
Conflict of interest: All authors declared that they do not have a
conflict of interest.
Open Access This article is distributed under the terms of the
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creativecommons.org/licenses/by/4.0/), which permits unrestricted
use, distribution, and reproduction in any medium, provided you give
appropriate credit to the original author(s) and the source, provide a
link to the Creative Commons license, and indicate if changes were
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