Xuxi Zhang

persons in the intervention group enrolling in care ‐ pathways. 26 Quantitative and qualitative results from the current study imply that persons in poor health might have enrolled less often, especially in falls and loneliness care ‐ pathways. Interventions in the falls and loneliness care ‐ pathways required persons to move to the training location and included active activities such as balance and strength training or social group activities. Persons who were limited in function might have not been able to participate in these activities. In most cities, care in the other care ‐ pathways for frailty and polypharmacy consisted of further assessment or referral to other care services. Which means these pathways required a less active involvement of older persons. Future interventions should develop strategies to reach older persons with limited functioning. Further adapting interventions to needs of groups with specific health problems were recommended by care professionals in this study. This is supported by findings from a large meta ‐ analysis of complex care interventions which found no benefits of any specific type of intervention and recommended tailoring of interventions to client needs. 19 In Rotterdam and Manchester, where enrolment into care ‐ pathways was particularly low, many persons reported wanting to solve health problems themselves and already being involved in other care as reasons for non ‐ enrolment. As explained earlier 26 , regular care for older persons in Manchester and Rotterdam was of high standard and the added benefit of the UHCE approach might have been small in these settings. 19 Older persons were generally satisfied with the UHCE approach. A main benefit for older persons was feeling that a care professional looked out for them. Feeling supported by and experiencing a better relationship with the care provider has also been reported in other coordinated care interventions. 40 ‐ 42 Trust appears to be the foundation of the relationship between care provider and older person and impacts on the acceptance of offered care. 43 ‐ 45 Also in our study, mistrust among older persons towards unfamiliar services and care providers was a main barrier towards participation in care. Psychosocial reasons were also a barrier towards care uptake in our study. Some older persons did not want to engage in activities that could put them in awkward social situations. Others did not feel confident enough to travel to activity locations because they were afraid of falling. It is therefore important for care professionals to focus on these psychosocial factors that influence care decisions. Even more so, because older persons themselves appear to prefer that care professionals focus on their psychosocial context. 45 There were differences between the health assessment indications as proposed in the general template and as used by cities. Cities reported sometimes using additional instruments or basing decisions on further clinical judgement. Cross ‐ cultural adaptation of health assessment instruments could improve medical decision ‐ making, such as has been done for the Tilburg Frailty Indicator in some countries. 46, 47 The extent of integration of the UHCE approach within the existing care system differed among cities. In Pallini, Rijeka and Valencia existing care was not available or referral to existing care was difficult. This could have impacted on the sustainability of the UHCE approach. Indeed, both participants and professionals in these cities mentioned they wished activities would continue beyond the project. 116 Chapter 5