AGnES: Supporting General Practitioners With Qualified Medical Practice Personnel Model Project Evaluation Regarding Quality and Acceptance

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1 ORIGINAL ARTICLE AGES: Supportig Geeral Practitioers With Qualified Medical Practice Persoel Model Project Evaluatio Regardig Quality ad Acceptace Neeltje va de Berg, Claudia Meike, Romy Heyma, Thomas Fiß, Eilee Suckert, Christia Pöller, Adia Dreier, Hage Rogalski, Thomas Karopka, Roma Opperma, Wolfgag Hoffma SUMMARY Backgroud: The Germa AGES (commuity-based, e-health-assisted systemic support for primary care) project allows geeral practitioers (GPs) to delegate certai elemets of medical care, icludig house calls, to qualified AGES employees ad thereby provide primary care to a larger umber of patiets. AGES projects of various types have bee carried out i a umber of Germa federal states from 2005 oward. I this article, a evaluatio of the AGES projects to date is preseted. Methods: Patiet data (age, sex, diagoses, level of care, mobility, etc.) ad each of the specific activities carried out i the AGES framework were documeted with stadardized computer-based istrumets. The GPs, AGES employees, ad patiets also uderwet stadardized iterviews. The acceptace of the AGES project, competece of the AGES employees, ad quality of medical care withi the projects were evaluated. The participatig GPs themselves assessed the quality of medical care. Results: By July 8, 2008, 8386 house calls o a total of 1486 patiets had bee made withi the framework of the AGES projects. The evaluatio revealed a high degree of acceptace of the project amog the participatig GPs, AGES employees, ad patiets. The GPs cosidered the quality of medical care withi the AGES project to be good for the vast majority of patiets. Coclusio: Structural redudacy is avoided by directly placig the AGES employees i the geeral practitioers' practices. Based o the results of the AGES projects, the law i Germay has ow bee ameded to eable implemetatio of the AGES project i the regular health care system from Jauary 2009 oward. The ext steps to be take are the establishmet of adequate reimbursemet withi the catalog of the statutory health isurace scheme ad a detailed defiitio of the required qualificatios. Dtsch Arztebl It 2009; 106(1 2): 3 9 DOI: /arztebl Key words: AGES, delegatio of medical care, primary care, medical practice persoel, physicia shortage D emographic developmets, especially the agig of the baby boomer geeratios ad risig life expectacy, are leadig to a icreasig proportio of elderly i Germay's total populatio. The proportio of persos aged 80 years old or over will grow to 7.4% by 2020 (i 2005: 4.5% [1]). I the rural areas of the ew Germa federal states, this tred will be itesified eve further by the emigratio of youg persos. Based o curret estimates, for example, by 2020 the proportio of persos aged 80 years or over will icrease to 8.2% i Bradeburg (2), to 8.6% i Meckleburg-Wester Pomeraia (3), ad to 9.6% i Saxoy (4). This chage i the age structure is havig a cosiderable impact o patiet umbers, especially as regards age-associated chroic diseases ad multimorbidity (5, 6). Age-related icreasig morbidity ad decreasig mobility will create a icreasig demad for, amog other thigs, physicia house calls. The age structure of geeral/family practitioers i private practice (GPs) is showig a similar tred to that of the geeral populatio. By 2011, about oe third of private practice GPs will have etered retiremet (7). By 2020, i Meckleburg-Wester Pomeraia for example, about 40% of these primary practice positios will eed to be refilled, eve assumig a retiremet age of 68 years (ow data). Sice the icreased demads placed o the primary medical care system as a cosequece of the agig of the populatio are also exacerbatig the problems may GPs experiece with fidig a successor, relevat deficits i outpatiet primary medical care are already aticipated withi a few years i some regios. AGES: commuity-based, e-health-assisted systemic support for primary care The AGES project is based o the delegatio of certai compoets of medical care, especially house calls. I areas with a aticipated or existig shortage of primary medical care, AGES ca support idividual GPs i providig care for a larger pael of patiets ad/or a larger area (8). The specific competecies of qualified AGES employees have ot yet bee formalized either by law or Istitut für Commuity Medicie, Erst-Moritz- Ardt-Uiversität Greifswald: Dr. rer. med. va de Berg, Dipl.-Psych. Meike, Dipl.-Kffr. Heyma, Dipl.-Pharm. Fiß, Dipl.-Pflegewirti (FH) Suckert, Pöller MSc, Dipl.-Pflegewirti (FH) Dreier, Prof. Dr. med. Hoffma MPH Fachbereich Gesudheit, Pflege, Maagemet, Hochschule Neubradeburg: Dipl.-Pflegewirt (FH) Rogalski, Prof. Dr. rer. cur. Opperma IT-Sciece-Ceter, Putbus: Dipl.-Ig. Karopka Deutsches Ärzteblatt Iteratioal Dtsch Arztebl It 2009; 106(1 2): 3 9 3

2 TABLE 1 The AGES practice projects Project Meckleburg- Meckleburg- Bradeburg Saxoy Saxoy-Ahalt Wester Pomeraia Wester Pomeraia (MoPra) Phase 1 3 Phase 4 Scheduled ru time 08/05 03/07 07/07 12/08 07/06 12/08 03/07 12/08 12/07 07/08 (3 phases) Fudig Miistry of Health Miistry of Health ESF ESF Miistry of ad Social Affairs ad Social Security Miistry of Miistry of Health ad ASHIP Labor, Social Affairs Social Affairs Social Affairs, ASHIP ASHIP Health, ad the Health isurace AOK Family fuds Project ICM Greifswald ICM Greifswald ICM Greifswald ICM Greifswald ICM Greifswald maagemet ASHIP ASHIP Qualified AGES persoel of whom primary qualified health ad ursig care medical assistat/medical employee Physicias Added to which are 14 qualified AGES employees from the project: Learig Curriculum Commuity Medicie Nursig (1 Ja 2006 to 31 December 2007, Sposor: EQUAL/ICareNet); ASHIP, Associatio of Statutory Health Isurace Physicias; ICM, Istitute for Commuity Medicie; ESF, Europea Social Fud; AOK, a large geeral statutory health isurace compay MoPra, mobile practice assistat otherwise. They deped o the primary qualificatio (urse or medical assistat), professioal experiece, ad further qualificatios. The competecies are defied by the patiets' characteristics (age, mobility, diagoses, care level) ad the ature of the delegated activities. The delegatio of house calls to practice employees is already possible, but receives oly a low level of remueratio ad makes o structural cotributio to primary medical care. Besides the stadardized moitorig of the patiet's state of health, the performace of medically delegated activities ad the provisio of couselig o specific topics, modules have bee developed for the followig aspects: Medicatio moitorig (i cooperatio with local pharmacists) Fall prevetio (icludig home ispectio) Telecare (telemedical devices for suitable patiets at home [9]) Telemedicie (use of mobile video coferece systems) Geriatric assessmet Palliative medicie. The implemetatio, documetatio requiremets, defiitio of services suitable for delegatio, as well as cotractual ad orgaizatioal aspects of the AGES project have bee developed ad tried out i private practice projects i four differet Germa federal states (table 1). The AGES model projects were evaluated o a stadardized basis with referece to the followig topics: Acceptace of the project Competecies of the AGES employees Quality of care. The results of this evaluatio are preseted i this article. Methods The basic priciple uderlyig all primary care practice projects is the delegatio of primary care services to qualified practice employees. The projects exhibit specific differeces i relatio to each other. The iitial projects AGES Meckleburg-Wester Pomeraia Phase 1 to 3 focused o feasibility i terms of cotet ad orgaizatio. I Bradeburg, the project was developed further i cooperatio with a medical care ceter ad the umber of delegated activities was cosiderably icreased. Saxoy was the federal state i which the project was first implemeted i primary care practices i areas with existig ad impedig shortages of medical care. I project Phase 4 i Meckleburg-Wester Pomeraia, the model was put ito practice i local etworks of GP practices: i these cases, the qualified AGES persoel work ot oly for their "core practice" but also for other GPs i the regio. The projects i Saxoy ad Meckleburg-Wester Pomeraia Phase 4 were sposored i terms of both 4 Deutsches Ärzteblatt Iteratioal Dtsch Arztebl It 2009; 106(1 2): 3 9

3 TABLE 2 Characteristics of the patiets i the differet projects (as i July 2008) Project Meckleburg- Meckleburg- Bradeburg Saxoy Saxoy- Curriculum Wester Pomeraia Wester Pomeraia Ahalt Neubrade- Phase 1 3 Phase 4 (MoPra) burg Number of patiets () Wome () Me () Age, mea (years) Age, rage (years) Mobility status Obligate house call patiet* 1 O demad house call patiet* 2 Practice attedace patiet * 3 Ukow 22 2 * 1 obligate house call patiet: mobility lost * 2 o demad house call patiet: restricted mobility * 3 practice attedace patiet: house call for optimizatio of treatmet MoPra, mobile practice assistat fudig ad cotet by the Associatios of Statutory Health Isurace Physicias ad the health isurace fuds of the various states. A more advaced fudig cocept is curretly beig implemeted i Saxoy- Ahalt; i this case, the participatig GPs ca charge the Natioal Associatio of Statutory Health Isurace Physicias ad the AOK (a large geeral statutory health isurace compay) for delegated house calls o the basis of a Agreemet to Implemet a Model Project pursuat to Sectios 63 ff of the Fifth Book of the Germa Social Security Code. The participatig GPs determie themselves which patiets ca be icluded i the projects, as well as the frequecy ad distributio of the house calls betwee the qualified AGES persoel ad the physicia. All activities of the AGES itervetio are recorded i a stadardized maer usig specially developed documetatio software (Karopka T et al.: ICT Architecture for a commuity medicie urse support project. Proceedigs of the First Iteratioal Coferece o Health Iformatics, Fuchal, Madeira, Portugal, Jauary 2008; pp ; Volume of Abstracts). The data recorded durig the house calls are etered directly i the patiet's home o a Tablet PC. The data are ecrypted ad trasmitted via a secure iteret coectio (VPN, virtual private etwork) to the Istitute for Commuity Medicie where they are checked for completeess ad plausibility. The acceptace of the project was surveyed amog GPs, AGES employees ad patiets usig stadardized questioaires. GPs were also requested to provide iformatio regardig the degree of workload relief provided by AGES, the required ad actual competecies of the AGES employees, ad the quality of medical care. Results Activities amog patiets O the referece date 8 July 2008, 1486 patiets had participated i oe of the AGES projects. The average patiet age was 78.6 years (rage, 21 to 107 years). The patiets are described i table 2. 91% of the patiets were immobile or oly partly mobile. The remaiig 9% would i priciple have bee capable of attedig the practice but were visited at home for reasos such as treatmet moitorig or other medically specified idicatios such as recordig of diural variatio i parameters such as blood pressure or blood glucose, assessmet of the care situatio at home or the social eviromet. The majority of participatig patiets were multimorbid (94.2%) (6). The mea umber of diagoses per patiet was six (rage, 1 to 27). The commoest diagoses were hypertesio (66%), diabetes (43%), coroary heart disease (24%), musculoskeletal diseases (22%), maligacies (14%), heart failure (13%), ad demetia (13%). The 53 participatig GPs delegated 8386 house calls to 38 qualified AGES employees of whom 32 Deutsches Ärzteblatt Iteratioal Dtsch Arztebl It 2009; 106(1 2): 3 9 5

4 TABLE 3 Questio: Does your pael of patiets iclude house call patiets that you do ot delegate to AGES i the model project? If so, please state the reaso. Reaso Capacity of AGES 12 Patiet's serious illess 11 Other reasos 6 Patiet's request 5 Family's request 4 Distace to / accessibility of patiet 4 Isufficiet specialized competece of AGES 2 27 physicias from the projects Meckleburg-Wester Pomeraia Phase 4, Bradeburg, Saxoy ad Saxoy-Ahalt, multiple selectios possible TABLE 4 Questio: Why are you cotiuig to make house calls yourself to patiets who are also visited by AGES? Reaso Acute exacerbatio of disease 31 Chaged frequecy of house calls 29 Impedig hospitalizatio 22 Patiet's serious medical coditio 21 Post hospital discharge care 17 Chage i therapy 15 Patiet's request 14 Maitaiig doctor-patiet cotact 13 Complex treatmet measures 9 Family's request 6 Other reasos 3 Isufficiet specialized competece of AGES 3 Lack of time for coordiatio with GP 1 42 physicias from the projects Meckleburg-Wester Pomeraia Phase 1 4, Curriculum Project Neubradeburg, Bradeburg, Saxoy, ad Saxoy-Ahalt, multiple selectios possible were urses ad 6 medical assistats. About 300 differet tasks were recorded (status July 2008). About 50% of the activities cocered the recordig of diagostic parameters such as blood pressure ad blood glucose values, weight, peak flow, body temperature, or ECG. Approximately 35% of these activities comprised the assessmet of physical ad metal state ad the documetatio of disease symptoms ad medically relevat evets such as falls, accidets, chages i social eviromet, medicatio-related problems ad care level assessmet by the Medical Service of the Statutory Health Isurace Compaies (MDK). Also icluded were couselig o health-related issues such as fluid itake, diet or the use of therapeutic products ad assistive devices. Further activities comprised medical tasks such as collectig blood samples, admiisterig ijectios, ad the treatmet of wouds ad pressure sores. Commo to all these activities is that they are part of the patiet's medical care, are ecessary ad ca be delegated to the qualified AGES employee as a meas of lighteig the GP's workload. Domiciliary ursig as well as core medical activities such as diagostic or therapeutic decisios, o the other had, are ot amog the fuctios of a AGES employee. Frequecy of house calls ad acceptace Of the 53 GPs i the AGES projects, 42 completed a stadardized evaluatio questioaire. I additio, detailed questioaires o the topic "Effect of AGES o practice operatio" were available from 27 of 39 physicias of the Meckleburg-Wester Pomeraia Phase 4, Bradeburg, Saxoy, ad Saxoy-Ahalt projects. These 27 GPs each had a average of 90 house call patiets (rage, 10 to 380) who were visited at least oce per quarter. For a average 67% ( = 60, rage 0 to 345) of these patiets, the GPs were of the opiio that part of the ecessary house calls could be carried out by the qualified AGES employees. The mai reasos for the project physicias ot delegatig house calls to practice persoel i a average of oe third of all house call patiets icluded the presece of serious illesses ad the exhausted capacity of AGES (table 3). I aswerig these questios, the physicias were able to choose from predefied categories, with the additioal optio to state reasos i free text. I the majority of patiets (15% to 100%, depedig o the GP) for whom house calls were delegated to practice staff, the treatig GP also made house calls him/herself. The ratioale for this is preseted i table 4. The mai reasos were impedig hospitalizatio ad acute exacerbatios of disease. 29 of the 42 GPs (69%) reduced the frequecy of house calls. The house calls o loger carried out were assumed by the qualified AGES employee. Most GPs (38 of 42) foud that the AGES project had a positive effect o their workload. Similarly, 37 of 6 Deutsches Ärzteblatt Iteratioal Dtsch Arztebl It 2009; 106(1 2): 3 9

5 42 GPs took the view that the qualified AGES employee house calls had a positive ifluece o patiet compliace (table 5). Compliace data were recorded i a stadardized fashio as part of the medicatio module. Iitial evaluatios also reveal beeficial effects i this area, for example as regards the mode ad timig of takig medicatio (Fiß T et al.: Das Modul Pharmazeutische Betreuug i AGES 3. Prävetio ud Gesudheitsförderug 2007: 2 [Suppl.] 102; Abstract). The patiet evaluatio of the projects was performed betwee December 2007 ad March All patiets from the ogoig projects who had participated for at least two moths ( = 992) were icluded. 67% of the distributed questioaires were retured completed ( = 667). 34 patiets died before the questioaires were retured, ad 22 patiets were ot capable of aswerig the questios for health reasos. The acceptace of the AGES project was very high. 629 of the 667 patiets (94.3%) could imagie a qualified AGES employee makig house calls ad performig special tasks such as fall prevetio ad telemedicie, ad that the GP eed oly make house calls i cases of urget medical ecessity. 658 of the 667 patiets (98.7%) expressed the opiio that the qualified AGES employee is ofte ( = 99, 14.8%) or always ( = 559, 83.8%) a competet cotact perso for health-related topics. Quality of medical care The GPs were requested to rate the followig statemet for every project patiet: "The shared medical care of the patiet by the GP ad AGES (o a delegated basis) durig the project period to date showed a similar quality to that of covetioal primary medical care" (project period to date: time betwee start of project ad time of survey; depedig o the project, betwee 2 moths [Meckleburg-Wester Pomeraia Phase 2] ad 1.5 years [Bradeburg]). The questio was aswered for 657 patiets. For 92.1% of these patiets, this statemet was rated as "very much agree" ( = 503) or "quite agree" ( = 102) by the participatig GPs (table 6). Relief of GP workload The results of the model projects were used to calculate the capacity of a qualified AGES employee. Mai parameters were complete time required for the house call (average 23 miutes); distace traveled per house call (average 8.4 kilometers); preparatio ad follow-up of house calls (about 16 miutes per house call), for example hadover briefigs with the GP arragig appoitmets with the patiet preparatio of blood sample tubes liaiso with ursig service ad pharmacist. Uder model coditios, this was extrapolated to a capacity of about 1200 house calls per year. The capacity freed by the resultig relief of GP workload (about 500 TABLE 5 Ratig of the statemets: "AGES positively iflueces the patiet's compliace" ad "AGES relieves the physicia's workload" ( = 42 physicias) "AGES relieves the "AGES positively iflueces physicia's workload" the patiet's compliace" Agree very much Quite agree 11 0 Partly agree 2 4 Hardly agree 1 - Do't agree 1 1 hours per year) ca the be devoted to treatig additioal patiets. Cooperatio with ursig services Nursig is ot amog the tasks of the qualified AGES employee. The assumptio of medical tasks by delegatio from the GP, however, expressly icludes patiets i eed of ursig care. Up to 43% of the house calls i the projects cocered ivolved patiets requirig ursig care (care level kow i 1119 patiets, of whom without care level, = 635; care level 1, = 283; care level 2, = 165; care level 3, = 36). I may of these cases, the qualified AGES employee acted as a importat iterface to the various ursig services. So far, ew or icreased ursig care eeds (as defied i the Fifth ad/or Eleveth Book of the Germa Social Security Code, status April 2008) have bee idetified i 109 patiets i the ogoig projects i Meckleburg- Wester Pomeraia, Bradeburg, ad Saxoy. For TABLE 6 Ratig of the statemet: "The shared medical care of the patiet by the GP ad AGES (o a delegated basis) durig the project period to date showed a similar quality to that of covetioal primary medical care" Number of patiets (%) Agree very much 503 (76.6) Quite agree 102 (15.5) Partly agree 32 (4.9) Hardly agree 9 (1.4) Do't agree 9 (1.4) No data 2 (0.3) Total 657 (100) Deutsches Ärzteblatt Iteratioal Dtsch Arztebl It 2009; 106(1 2): 3 9 7

6 BOX Legal framework coditios Uder the terms of the Nursig Care Advacemet Act (adopted by the Germa Federal Parliamet o 14 March 2008), Sectio 87 2b of the Fifth Book of the Germa Social Security Code was ameded with the followig supplemet at the iitiative of the "AGES Steerig Group" i which represetatives of all social miistries of the ew Germa federal states cooperate: "At the latest by 31 October 2008 ad with effect from 1 Jauary 2009, a regulatio is to be itroduced whereby medically directed assistace by other persos pursuat to Sectio 28 Subsectio 1 Para. 2 which is provided at the patiet's home i the physicia's absece is to be remuerated". The commets of the Germa Federal Coucil o this amedmet of the Act of 30 November 2007 refer explicitly to the AGES project as a model for the delegatio of medical services i the domiciliary settig (Germa Federal Coucil publicatio 718/1/07). example, overburdeig of relatives was idetified, assistace i applyig for a care level was provided, ad the eed for ursig i woud maagemet or admiisterig medicatios were established. As a cosequece, a ursig service was subsequetly itegrated ito the patiet's care program i most cases. Discussio ad prospects Cosiderig the high relevace for medical practice, the AGES project has stimulated great iterest. Aspects of cetral relevace were see to be the relevace of the project for solvig problems of deliverig medical care i rural areas; the legal framework coditios (box); iterfaces to other health care professios; curricular cotets of the required qualificatios of the qualified AGES employees; fudig of AGES i the regular health care system. Relevace for rural areas with health care shortages It is evidet from the project described that it is ot the goal of AGES either to replace private practice physicias or to substitute compoets of primary medical care delivery with other professioal groups. The uderlyig philosophy is rather to delegate medical services uder the GP's resposibility. Sice domiciliary ursig is explicitly ot amog the tasks of AGES, there is o competitio with ursig services. O the cotrary, i may cases ew or icreased ursig requiremets were idetified ad a ursig service called i. The aim of the AGES project is rather to cotribute, through iovative optios of iterdiscipliary cooperatio betwee GPs ad qualified medical persoel, to securig outpatiet medical care i regios facig shortfalls i medical care provisio. The results of the model projects suggest that the AGES project ca effectively improve the situatio of primary medical care i regios at risk of deficiet levels of medical care delivery. The evaluatio demostrates the high acceptace of AGES amog the participatig patiets. The project desig meat that the choice of patiets was solely the prerogative of the GPs. It is therefore ucertai to what extet these results are represetative of all the patiets as a whole. The acceptace, however, is coupled to the certaity that i cases of medical ecessity the house calls will be made by the physicias themselves. Durig the project phase, the majority of participatig GPs already experieced the support provided by the qualified AGES employees as relievig their workload. They also rated the quality of medical care as high ad for most patiets as equivalet to covetioal primary medical care. The majority of physicias were also of the opiio that the project had a positive ifluece o their patiets' compliace. At the 111 th Germa Physicias' Cogress (Ulm, 20 to 23 May 2008), the delegates for the first time came out clearly i favor of icreasigly delegatig activities to other health care professioals. The essetial precoditio, however, is that the physicia retais overall therapeutic resposibility. Substitutio of medical services was rejected. I the decisio memoradum of the 111 th Germa Physicias' Cogress, the AGES projects were cited as positive examples of iovative delegatio projects (10). Limitatios The quality of medical care was rated by the participatig GPs as part of the described evaluatio. I further steps, objective parameters for quality measuremet, such as blood pressure values ad patiet quality of life, were evaluated. The AGES projects were devised as feasibility ad qualificatio projects. Sice o cotrol group so far exists with which the project results ca be compared, i a ext step secodary data will be requested from the health isurace fuds ad the Associatios of Statutory Health Isurace Physicias i the various Germa federal states. The aim is to mout comparisos betwee project patiets ad other isured persos of the participatig medical practices (for example the ratio betwee the umber of physicia/qualified AGES employee house calls) ad at the regioal level (quatificatio of the systemic itervetio effect). The secodary data will oly be available with a cosiderable delay ad could ot be icluded i this article. Qualificatio Qualificatio aimed at allowig the performace of delegated medical activities i house calls ad based o existig specialized competecies is of cetral importace for the successful implemetatio of the AGES project. Basic qualificatios i this cotext are the skills of urse specialists ad medical assistats/qualified medical 8 Deutsches Ärzteblatt Iteratioal Dtsch Arztebl It 2009; 106(1 2): 3 9

7 Key messages The icrease i morbidity associated with demographic chage ad the emergig shortage of physicias is jeopardizig primary medical care i structurally weak rural areas. To maitai close-to-home care, the workload of the remaiig physicias must be relieved by providig icreased scope for delegatio. The AGES model demostrates that medical practice employees, traied by the primary care physicia, ca provide delegated medical services of high quality. Career developmet as a qualified AGES employee is a attractive professioal perspective for health care professioals ad urses, medical assistats, ad qualified medical employees. Based o a amedmet to the Act i March 2008, the model will be itroduced ito the regular health care system with effect from 1 Jauary employees. I collaboratio with the Neubradeburg Uiversity of Applied Scieces, a curriculum for the AGES project was developed which directly icorporates the practical experiece gaied i the AGES projects. Differeces i primary qualificatio ad the breadth of experiece of the practice employees are idividually compesated by appropriate modules (11). Besides defiig the relevat qualificatios, the ext importat milestoe for the Evaluatio Committee is to establish adequate reimbursemet withi the catalog of the statutory health isurace scheme for the delegatio of patiet house call services to medical practice employees. If these efforts are successful o the basis of mutual agreemet with the parties cocered, the model projects ca be implemeted i the regular health care system from 1 Jauary 2009 owards. Coflict of iterest statemet The authors declare that o coflict of iterest exists accordig to the guidelies of the Iteratioal Committee of Medical Joural Editors. Mauscript received o 16 Jue 2008, revised versio accepted o 21 October Traslated from the origial Germa by mt-g. REFERENCES 1. Statistisches Budesamt: Bevölkerug Deutschlads bis koordiierte Bevölkerugsvorausberechug. Wiesbade Amt für Statistik Berli-Bradeburg: Bevölkerugsprogose des Lades Bradeburg für de Zeitraum Statistischer Bericht A Potsdam Statistisches Amt Meckleburg-Vorpommer: 3. Ladesprogose zur Bevölkerugsetwicklug i Meckleburg-Vorpommer bis 2020 Überarbeitete Fassug Statistische Berichte Bevölkerugsstad. Schweri Statistisches Ladesamt des Freistaates Sachse: 4. regioalisierte Bevölkerugsprogose für de Freistaat Sachse bis Fedrich K, Hoffma W: More tha just agig societies: the demographic chage has a impact o actual umbers of patiets. J Public Health 2007;15: Va de Akker M, Butix F, Roos, S, Kotterus JA: Problems i determiig occurece rates of multimorbidity. J Cli Epidemiol 2001; 54: Kopetsch T: Dem deutsche Gesudheitswese gehe die Ärzte aus! Studie zur Altersstruktur ud Arztzahletwicklug, 3. Auflage. Berli: Kasseärztliche Budesvereiigug Va de Berg N, Meike C, Heyma R, Dreier A, Terschüre C, Hoffma W: Commuity Medicie Nurses Arztuterstützug i lädliche Regioe. Pflege & Gesellschaft 2007; 12: Terschüre C, Fedrich K, va de Berg N et al.: Implemetig telemoitorig i the daily routie of a GP practice i a rural settig i orther Germay. J Telemed Telecare 2007; 13: Budesärztekammer: Beschlussprotokoll des 111. Deutsche Ärztetages vom Mai 2008 i Ulm. ETBeschlussprotokoll pdf, Rogalski H, Dreier A, Hoffma W, Opperma R : Commuity Medicie Nurse Die Tele-Gesudheitsschwester. Die Schwester. Der Pfleger 2008; 1: Correspodig author Prof. Dr. med.wolfgag Hoffma, MPH Istitut für Commuity Medicie Abteilug Versorgugsepidemiologie ud Commuity Health Kliikum der Erst-Moritz-Ardt-Uiversität Greifswald A.ö.R. Ellerholzstr. 1/ Greifswald, Germay wolfgag.hoffma@ui-greifswald.de Deutsches Ärzteblatt Iteratioal Dtsch Arztebl It 2009; 106(1 2): 3 9 9