LoChro-Care intervention
CCM
LoChro-Care was designed as a local, collaborative, stepped, and personalized care intervention. It focuses on enhancing the patients’ self-management in coordinating their individual care network by providing assistance to maintain or establish contact to formal and informal support (e.g., general practitioner, family, regional geriatric outpatient services). It comprised 7–16 contacts with trained chronic care managers (CCM) and lasted 12 months. A total of four CCM with extensive experience in the sectors of nursing, health education, and social work provided the intervention (qualifications: CCM 1: Bachelor of Science (BSc) Nursing Science, nurse; CCM 2: Master of Arts (MA) Health Education, nurse; CCM 3: MA Social Work; CCM 4: BSc Health Education, MA Social Work student). At least the first three contacts were home visits. Depending on the constitution of the patient, the monitoring contacts could also take place by telephone. From the beginning of 2020, the intervention contacts were conducted exclusively by telephone due to the COVID-19 pandemic. Figure Elements of the LoChro-Care intervention