Table 1 Features of multidisciplinary teams and multidisciplinary team meetings

Caregivers, attending focus-group interviews

1 GP

1 GP

1 GP

2 GPs

1 practice nurse

3 community nurses

2 practice nurses

2 practices nurses

3 community nurses

2 NHPSs

3 community nurses

2 community nurses

2 physiotherapists

1 occupational therapist

1 mental health nurse

2 NHPSs

1 occupational therapist

1 welfare worker

2 physiotherapists

2 welfare workers

2 welfare workers

1 health broker

1 welfare worker

1 centre manager

1 dietician

1 health broker

Service area multidisciplinary team

4800 patients

2150 patients

7000 patients

38,000 patients

Demographic features

Village with 22,555 inhabitants, 15% = 65+ years

Deprived neighbourhood in a medium-sized city with 168,292 inhabitants, 14% = 65+ years

Commuters; neighbourhood with old village centre in medium-sized city with 168,292 inhabitants, 14% = 65+ years

Small town with 41,775 inhabitants, 15% = 65+ years

GP setting

General practice

General practice

Health centre

Health centre

 Date of foundation

2014

2011

1961

2011

 MTM chairperson

GP

GP

GP

NHPS

 Target group

Frail older people, 65+ years

Frail older people, 75+ years, exceptions allowed

Frail older people, 70+ years, exceptions allowed

Frail older people, 65+ years

 Submission of cases

Screening

Screening

Case-finding

Case-finding

 Follow-up

Case manager, care plan

Case manager, care plan, minutes, EPR, Care and Welfare Information Portal (ZWIP)

Case manager, minutes, EPR, Care and Welfare Information Portal (ZWIP)

Care plan, EPR

 Funding

Research subsidy

Care programme by health insurer

Health insurer, funding for health centres

Research subsidy, local community health services

 Coordination

Practice nurse

Community nurse

Practice nurse

Practice nurse

 Frequency

1 × 3 months

1 × month

1 × month

On indication