Holistic Care Program for Elderly Patients to Integrate Spiritual Needs, Social Activity and Self-Care into Disease Management in Primary Care

INTERVENTION: Intervention 1: In the intervention group, GPs (general practitioners) will conduct a “spiritual needs assessmentâ€? during the routinely planned DMP (Disease Management Programs) appointments and explore whether the patient has a need for more social contact or self‐care. To enable GPs to react on such needs, several aids will be provided by the study: a) training of GPs in spiritual needs assessment, training of medical assistants in motivational interviewing; b) access to a web‐portal with a summary of regional social offers for seniors; c) information leaflets on non‐pharmacological interventions focusing on home remedies to be applied by patients themselves to reduce frequent symptoms in old age. Intervention 2: In the control group, GPs will conduct DMPs as usual. CONDITION: multimorbidity # polypharmacy PRIMARY OUTCOME: Self‐efficacy (measured by the SES‐6G scale) at T0 (baseline) and T1 (6 months after spiritual needs assessment) SECONDARY OUTCOME: General Self‐efficacy (GSES); Patient activation (PAM); Mental and physical health (SF12); Beliefs in medicine (BMQ); Medication adherence (MARS); Satisfaction with GP care (EUROPEP); Work satisfaction (Warr‐Cook‐Wall scale); Size of Social Network (LSNS); Loneliness (DJGS); ; All outcomes will be measured at T0 (baseline) and T1 (6 months after the spiritual needs assessment) INCLUSION CRITERIA: Inclusion criteria for patients: 70 years or older, at least 3 chronic conditions, at least 3 medications, participation in at least one DMP, ability to give informed consent and to participate actively in the study. Inclusion criteria for GPs: participation in at least one DMP.