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STUDY PROTOCOL
COMPASS II—Coordination of Medical
Professions Aiming at Sustainable Support
Protocol for a feasibility study of cooperation
between general practitioner practices and
community care points
Lisa PeterID*, Judith Stumm, Cornelia Wa
¨scher, Lisa Ku¨mpel, Christoph Heintze,
Susanne Do
¨pfmer
Institute of General Practice and Family Medicine, Charite
´- Universita
¨tsmedizin Berlin, Corporate Member of
Freie Universita
¨t Berlin and Humboldt-Universita
¨t zu Berlin, Berlin, Germany
*lisa.peter@charite.de
Abstract
Introduction
General practitioners (GP) increasingly face the challenge of meeting the complex care
needs of multi-morbid patients. Previous studies show that GP practices would like support
from other institutions in advising on social aspects of care for multi-morbid patients. Already
existing counselling services, like community care points, are not sufficiently known by both
GPs and patients. The aim of COMPASS II is to investigate the feasibility of cooperation
between GP practices and community care points.
Methods and analysis
During the intervention, GPs send eligible multi-morbid patients with social care needs to a
community care point. The community care points report the consultation results back to the
GPs. In preparation for the intervention, in a moderated process, GP practices meet with the
community care points to agree on information exchange. The primary outcome is the feasi-
bility of the cooperation: Questionnaires will be sent to GPs, medical practice assistances
and community care point personnel (focus: practicality, acceptability). Data will be collected
on frequency and reasons for GP-initiated consultations at community care points (focus:
demand). Qualitative interviews will be conducted with all participating groups (focus:
acceptability, satisfaction). The secondary outcome is the assessment of changes in health-
related quality of life, social support and satisfaction with care: participating patients com-
plete a questionnaire before and three to six months after their counselling. The results of
the study will be incorporated into a manual in which the experiences of the cooperation will
be made available to other GP practices and community care points.
Discussion
In COMPASS II, GP practices establish cooperation with community care points. The latter
are already existing institutions that provide independent and free advice on social matters.
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OPEN ACCESS
Citation: Peter L, Stumm J, Wa¨scher C, Ku¨mpel L,
Heintze C, Do¨pfmer S (2022) COMPASS II—
Coordination of Medical Professions Aiming at
Sustainable Support Protocol for a feasibility study
of cooperation between general practitioner
practices and community care points. PLoS ONE
17(9): e0273212. https://doi.org/10.1371/journal.
pone.0273212
Editor: Lucinda Shen, Public Library of Science,
UNITED KINGDOM
Received: July 25, 2022
Accepted: August 2, 2022
Published: September 6, 2022
Peer Review History: PLOS recognizes the
benefits of transparency in the peer review
process; therefore, we enable the publication of
all of the content of peer review and author
responses alongside final, published articles. The
editorial history of this article is available here:
https://doi.org/10.1371/journal.pone.0273212
Copyright: ©2022 Peter et al. This is an open
access article distributed under the terms of the
Creative Commons Attribution License, which
permits unrestricted use, distribution, and
reproduction in any medium, provided the original
author and source are credited.
Data Availability Statement: No datasets were
generated or analysed during the current study. All
By using an existing institution, the established cooperation and experiences from the study
can be used beyond the end of the study.
Trial registration
The trial is registered with DRKS-ID: DRKS00023798, Coordination of Medical Professions
Aiming at Sustainable Support II.
Introduction
It is well known that in Germany, due to demographic change, the proportion of people over
60 is growing in combination with an increase in chronic diseases and multi-morbidity [1–4],
while the number of GPs is declining [5,6]. Providing sufficient and qualified care for these
patients is a challenge for the German healthcare system. As early as 2010, Scheidt-Nave called
for health research to develop "care models adapted to the needs of specific subgroups of older
people," such as patients with multi-morbidity [3].
Results from a prior funding phase of COMPASS showed the GPs need for support in the
management of care for patients with multi-morbidity. Interviews with GPs and medical prac-
tice assistants in Berlin revealed that the unmet social needs of patients with multi-morbidity
are a major concern [7]. GPs do not have sufficient resources to address social issues and
would welcome further support, such as better information about and access to social counsel-
ling and community services [7–9].
In 2008, German legislation required statutory health and long-term care insurance funds
to set up “Pflegestu¨tzpunkte” (in this article it is referred to as community care points) in coop-
eration with the local authorities. The German Social Insurance Code XI defines the following
responsibilities of community care points: coordination of home and community-based care,
support in nursing and social needs, and support for the utilization of health services [10,11].
The services of the community care points are independent and free of charge [12]. However,
community care points are not well known among the general population [13]. Although com-
munity care points offer low threshold community care, they are not used as widely as
intended [14]. Focus groups with GPs in Berlin revealed that they have limited or no experi-
ence collaborating with community care points [15]. The common practice in dealing with
social consulting issues differs between GP practices [7]. Many GPs conduct the consultation
on their own, often without an adequately competent background and with restricted time
resources [7,15].
To our knowledge, no project has been undertaken to connect GP practices and commu-
nity care points with the aim, firstly, to improve utilization of community care points by
multi-morbid patients in need and, secondly, to decrease the GPs workload to cope with
demographic change.
Context
COMPASS II is a sub-project of the NAVICARE network for patient-oriented health care
research, which aims to reduce barriers and inequalities in the care of patients with age-associ-
ated diseases. COMPASS II lays a focus on multi-morbid patients in primary care.
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relevant data from this study will be made available
upon study completion.
Funding: COMPASS is part of the research
consortium “NAVICARE – Patient-oriented health
services research” and is funded by the German
Ministry of Education and Research (01GY1911).
Competing interests: The authors have declared
that no competing interests exist.
Methods
Aim
The aim of COMPASS II is to initiate and explore the feasibility of cooperation between GPs
and community care points to meet the social needs of multi-morbid patients. The planned
intervention will raise awareness about community care point services among GPs and prac-
tice teams and may help to decrease the workload of GPs [16].
Study design
This is a feasibility study combining descriptive quantitative data and qualitative interviews in
a mixed-method approach, addressing the dimensions of acceptability, practicability, satisfac-
tion and demand. Patient outcomes will be investigated by performing two questionnaire-
based assessments, at baseline t0 (before counselling at the community care point) and three to
six months later (t1).
Study setting
The study will be conducted in two Berlin city districts, Tempelhof-Schoeneberg and Charlot-
tenburg-Wilmersdorf, comprising 690,931 inhabitants (18.9% of the Berlin population, Status
31/12/2020) and 555 GPs [17–20]. In each district, there are three community care points.
Participating GPs include patients during their usual care consultations. The research team
conducts quantitative and qualitative feasibility investigations. The patient assessments will be
performed by the medical practice assistants of the participating GP practices.
Sample size and power considerations
As we plan to conduct an exploratory feasibility study, we did not perform a sample size calcu-
lation. Our estimates of the number of participating GPs and patients are pragmatic and are
based on the following considerations: from our experience with other studies, we assume, a
participation rate of 5–10% related to the 555 GPs listed by the Berlin Association of Statutory
Health Insurance Physicians in the study as feasible [19]. We further assume that recruiting 10
patients per GP per 15 months is feasible.
Recruitment and retention strategies
Participants/eligibility criteria. All GPs and community care points in the two Berlin
city districts will be invited to participate in the study. There are no exclusion criteria.
Up to 15 patients will be recruited by each GP for the study. The inclusion and exclusion
criteria are listed in Table 1.
Table 1. Inclusion and exclusion criteria for participants.
Inclusion criteria • at least 18 years old
• patient in a participating GP practice
• multi-morbidity (at least two chronic diseases)
• need for social consultation
• motivation for a community care point consultation
• willingness to take part in the study
• competency to answer the assessment questionnaire at two points in time
Exclusion criteria • living in a nursing home
• private insurance
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Patients who are not able to speak for themselves may be represented by family carers who
are spouses/partners or family members living in the same household and who have a legal
certificate of representation.
All participants may choose to terminate their participation in the study at any time.
Regardless of whether the patients participate in the study or not, they will receive usual care at
the GP practice indiscriminately and can seek advice at any community care point.
Participant timeline. Community care point enrolment was started and completed in
2020. GP enrolment started in November 2020 and lasted until January 2022. GPs were
enrolled into the ongoing intervention in 3 cohorts, starting with the attendance at a coopera-
tion meeting in April, September and December 2021. Patient recruitment started in July 2021
and will end in September 2022. The last patient out will be in December 2022.
Recruitment of community care points, GP practices and patients. All community care
points (n = 6) in the two city districts were invited to participate in the study. All participating
personnel of the community care points received information about the study and were asked
to provide written consent.
GP identification was based on the list of all statutory health registered GPs in the two Ber-
lin city districts. GPs were contacted by mail as well as by telephone and were invited to partic-
ipate in the study. Due to the expected difficulties in recruitment during the Covid-19
pandemic, an adaptive recruitment procedure was applied: recruitment continued beyond the
start of the intervention in July 2021 until January 2022 and GPs were invited to participate in
the study on multiple occasions. Informative meetings were held for GPs and their medical
practice assistants using online formats. At the start of participation in the study, a cooperation
meeting between GP practices and the staff of the community care points took place. In the
following practice visit, the study nurse provided information about the study and required
study documents (study information and consent for patients, templates for documentation).
During this visit, she obtained written informed consent from all participating GPs and medi-
cal practice assistances. Subsequently, the medical practice assistances were trained in support-
ing the patient assessment. This training included, among other things, information about
when and how to support patients. This could, for example, be to clarify questions of under-
standing from patients and emphasises the importance of preparing a memo for the second
patient assessment (t1).
Patients are identified by the GPs during routine consultations of the patient in the GP
practice or during a home visit. If a social counselling need becomes apparent, the patient is
asked by the GP to participate in the study. Written consent will be obtained, including a
release from confidentiality in the informational exchange with the community care points.
Retention strategies. The study nurse conducts both monthly scheduled practice visits
and short-term practice visits. The research team provides short-term answers and individual
solutions to any upcoming challenges or doubts reported by the GPs or their medical practice
assistances. The study nurse is available by telephone and e-mail five days a week for short-
term queries.
Financial incentives are provided for participating in the cooperation meetings and the
training for medical practice assistances, as well as for each patient inclusion.
Intervention
Cooperation meetings. The intervention started for every participating GP practice by
taking part in a cooperation meeting with the community care point personnel and other GP
practices participating in the study. The cooperation meeting was facilitated and moderated by
the research team. The mode of sending patients, communication, and reports was agreed on
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between the two parties. Every participating GP and their medical practice assistants were
invited to take part in the cooperation meetings to be able to contribute to the agreements. If
for any reason a GP was not able to attend any of the meetings, they were asked to comply
with the agreements made by other GPs and community care points and got the opportunity
of an individual low-threshold meeting with the community care point they prefer to cooper-
ate with. GP practices usually establish cooperation with one to two community care points in
their area.
Due to recruiting difficulties during the Covid-19 pandemic, the inclusion of GP practices
followed an adaptive approach. Therefore, cooperation meetings were offered consecutively at
three points over a period of 9 months (April 2021, September 2021, and December 2021).
Intervention then started for the participating GPs after attending the cooperation meeting.
Patient visits at the community care points. Eligible patients who give their consent to
take part in the study will be asked to make an appointment at the community care point clos-
est to their home or GP practice. GPs will give them a form with a short description of the con-
sultation issues to hand over to the community care point. Alternatively, when required by the
patient, an appointment with the community care point will be arranged immediately by the
GP by phone. The contact details of the community care point will be handed to the partici-
pants by the GP. For all participating patients, the GP practice prepares a memo for the second
patient assessment (t1) three to six months after the consultation, which takes place during a
routine visit of the patient at the GP practice. Patients who do not give their consent to take
part in the study are free to visit a community care point but will not be included in the study.
Consultation by the community care point can be provided at the community care point
office (by default) or alternatively by phone or by home visits (depending on the current regu-
lations concerning the Covid-19 pandemic. Consultation may consist of several contacts. The
community care point will send a short report about the consultation, the results, measures
undertaken, and, where necessary, advice for further proceedings to the GP practice (S1 Fig:
Flowchart for recruitment and study process).
Study structure
COMPASS II is a mixed methods study composed of the following methodological
approaches:
Quantitative section. Logbooks on consultations and patient recruitment. The community
care points will compile a logbook of every consultation issue and report consultation fre-
quency during the intervention period without including patient data. In addition, a logbook
is kept in each GP practice in which the number of patients considered eligible by the GPs, the
number of patients who participate in the study or refuse to participate, and the reasons for
refusal and drop-outs (all anonymous) are recorded. Logbooks of GP practices and commu-
nity care points are used to assess the dimension of demand.
Questionnaires with GPs,medical practice assistants and community care point personnel. At
the end of the intervention, all participating GPs and all medical practice assistants will be
asked to fill in a questionnaire on their view of the utilization of the community care points
and about their experience of (workload) relief by delegating social consultancy needs to the
community care points. The community care point personnel will also receive a questionnaire
on their assessment of the use of the community care points within the study. The question-
naires will focus on the dimensions of practicability, acceptability, and satisfaction.
Patient assessment. The research team developed a patient assessment to determine the
change in the quality of life, satisfaction with care, and social support after the consultation in
the community care point. Some of the items were self-constructed. Items from validated
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questionnaires (Geda-Ehis 2019/2020, Brief Social Support Scale, DeJong Giervield Loneliness
Short Scale) were added to the patient assessment [21–23]. One other validated questionnaires
was slightly adapted and converted into simpler language to better reach the multi-morbid
patients [24].
Patients receive the same questionnaire before and three to six months after their counsel-
ling session. The assessment will be collected pseudonymously to allow pre- and post-compari-
sons. The practices are provided with a list of pseudonyms to be applied to participating
patients. The list is held at the practice and the research team has no access to it. The assess-
ments are paper-based and are to be collected during regular visits to the practice by the study
nurse.
Qualitative section. Interviews with GP,medical practice assistance,community care point
personnel and patients. A subgroup of a minimum of eight GPs, a minimum of eight medical
practice assistants, and two staff members of each participating community care point (a mini-
mum of 6 staff members), as well as a minimum of 15 patients, have been asked to take part in
qualitative interviews on their experience of the cooperation. The first interviews were con-
ducted eight months after the start of the intervention. The last interview will be conducted up
to two months after the end of the intervention. The dimensions of acceptability and satisfac-
tion with the cooperation will be assessed during these interviews. Personal data of the respon-
dents have been collected (age, gender, living situation of the patients, professional experience
of the GPs and practice assistants, specialization of the GPs, number of staff in the practice,
type of practice). All qualitative interviews are semi-structured and an interview guideline is to
be used. Interviews have been digitally recorded and transcribed verbatim. All identifying fac-
tors have been removed during transcription. Written informed consent for the interviews
was already obtained at the study inclusion.
Outcomes
Primary outcome. The primary outcome is the feasibility of the cooperation of general
practitioners and community care points in the dimensions of acceptability, demand, satisfac-
tion, and practicability (Table 2).
Secondary outcome. Secondary outcomes are:
• Patient-reported outcomes such as quality of life, satisfaction with care and social support.
• Development of a manual with best practice examples for the cooperation between GPs and
community care points planned to be disseminated to other GP practices and the interested
public.
Table 2. Dimensions, indicators of feasibility and methods in COMPASS II.
Dimension Indicator Method
Acceptability • perceived effects and appropriateness of the cooperation and satisfaction with the results, from the view of GPs, medical
practice assistances, patients, and community care points
Qualitative interviews
• % GPs, medical practice assistances, community care point personnel satisfied with the intervention; % GPs being relieved
from workload by use of community care point service
Quantitative
questionnaires
Demand • frequency and reasons for consultation of the community care points Logbooks
Satisfaction • satisfaction with intervention in the view of GPs, medical practice assistances, patients and community care points Qualitative interviews
Practicability • steps taken, communication paths, success or failure of referring patients to the community care points from the view of
GPs, medical practice assistances, patients and community care points
Qualitative interviews
Quantitative
questionnaires
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Data analysis plan
The data collected from logbooks will be summarised thematically. Descriptive statistical anal-
yses on recruitment and dropouts will be conducted to determine the feasibility of the study.
Data on counselling issues collected from community care points will be grouped and catego-
rized using qualitative methods.
The items of the questionnaire on the feasibility of the cooperation will be analyzed descrip-
tively. Bivariate or multivariate analyses will be conducted exploratively to make assumptions
about relationships between feasibility and practice/GP characteristics. IBM SPSS Statistics
will be used for the analysis.
The assessment of patient-related outcomes will be analyzed descriptively, comparing the
results before and after the patients’ visit to the community care point.
Qualitative interviews will be analyzed using the framework analysis methodology [25].
The analysis takes place within a multidisciplinary team. The researchers familiarize them-
selves with the audio recordings and transcripts, jointly design coding with an inductive and
deductive approach, apply the coding to the material, and bring the analysis to consensus
through discussions. For data analyses and coding, the qualitative analysis software program
MAXQDA1(VERBI Software GmbH, Germany) will be used.
All analysis steps are discussed in the regular research forum of the Institute of General
Practice and Family Medicine of the Charite
´- Universitaetsmedizin Berlin.
Data management
Data collection and data entry is performed by the research team and monitored by an experi-
enced researcher from the research team. Each participant (GPs, medical practice assistances,
patients, staff members of the community care points and patients) is to be assigned an indi-
vidual pseudonym. The pseudonym lists remain in the GP´s practices or the community care
point offices. The data collected in paper form is stored securely in a locker at the Institute of
General Practice and Family Medicine of the Charite
´- Universitaetsmedizin Berlin or in a
password-protected server area. Only the research team has access to the final study dataset.
The coordinator of the NAVICARE network will conduct one independent audit halfway
through the study period. The coordinator of NAVICARE is independent of the COMPASS
research team and the sponsor.
Dissemination of results
The relevant results will be published in national and international journals. The manual
developed as part of the study with best practice examples for the cooperation between GPs
and community care points will be provided to other GPs and community care points in Berlin
and Germany.
Additionally, research findings will be disseminated to patients and family caregivers,
researchers, healthcare providers and other stakeholders, as well as the general public through
the NAVICARE network’s website (https://navicare.berlin/de/), Twitter account (https://
twitter.com/NAVICARE_Berlin), annual symposia, presentations at partnering institutions’
events and scientific conferences, and peer-reviewed publications.
Ethical considerations
Ethical approval was obtained from the Ethics Commission of Charite
´- Universitaetsmedizin
Berlin, Germany (EA1/146/20, July 27, 2020).
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Discussion
In light of demographic change, GPs are facing an increasing workload [5,26,27]. To meet
these challenges, GPs need and want support [7,8,15,27,28]. In preliminary studies, there
was evidence that, in addition to administrative matters, it is primarily concerning social coun-
selling issues that GPs want to refer to other health care professionals in the care of multi-mor-
bid patients [7,8,15]. Zimmermann et al. also showed in a survey of German GPs that social
issues are a frequent reason for consultation and that GPs express further interest in institu-
tionalized support for this [9]. In the Dutch program "Welzijn op Recept", GPs can refer
patients with psychosocial problems to local social well-being organizations [29]. Here, as in
similar projects, a workforce specially trained for the project is needed to assess the individual
needs of patients and refer them to the appropriate institutions [29–32]. This requires addi-
tional resources, both human and financial [30,33], which may be available in the context of
funded projects but may not prevail beyond the end of the study.
For some years now, there have been community care points in Germany, which are
financed by the statutory health insurance funds and local authorities and offer free and inde-
pendent advice on social issues [10–12]. Although the community points are not very well
known thus far [13], in a survey of GPs in Berlin, the majority indicated that community care
points could be a source of support for them when caring for patients with complex care
needs. [8]. A study in London, which examined the perspective of GPs on barriers to integra-
tion between primary and social care revealed poor inter-professional relationships as one bar-
rier [34]. For these reasons, COMPASS II aims at supporting family physicians in establishing
cooperation with the already existing institution of community care points. By using an exist-
ing institution, the cooperation established during the study can continue beyond the end of
the project. The experiences of GPs and community care points gathered in the study will be
passed on to other GPs and community care points with the help of a manual. In this way,
COMPASS II will continue to contribute to the establishment of further cooperation after the
end of the study and will increase the awareness of community care points [16].
One difficulty in the implementation of the study is the Covid-19 pandemic, which is asso-
ciated with recruitment difficulties of GP practices due to further increased workload [35]. To
counter this, the recruitment was adapted, and the GP practices were offered individual solu-
tions as an alternative to the potentially time-consuming cooperation meetings to get in con-
tact with the community care points at the start of the study. In addition, the period during
which patients can be enrolled in the study has been extended.
Supporting information
S1 Fig. Flowchart for recruitment and study process.
(TIF)
Acknowledgments
The authors would like to thank the Berlin Senate for its involvement in the development of
this study and all participating GPs, MPAs and community care point personnel who take part
in the study.
Author Contributions
Conceptualization: Lisa Peter, Judith Stumm, Christoph Heintze, Susanne Do¨pfmer.
Data curation: Cornelia Wa¨scher.
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Investigation: Lisa Peter, Judith Stumm.
Project administration: Christoph Heintze, Susanne Do¨pfmer.
Writing – original draft: Lisa Peter, Lisa Ku¨mpel, Susanne Do¨pfmer.
Writing – review & editing: Lisa Peter, Judith Stumm, Cornelia Wa¨scher, Lisa Ku¨mpel, Chris-
toph Heintze, Susanne Do¨pfmer.
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