Staying Functionally Independent

Staying Functionally Independent: Understanding and Supporting Functional Independence in Older People As population ageing accelerates, maintaining Functional Independence (FI) in older people has become a key priority for healthcare systems. In the Netherlands, policy initiatives such as the Integrated Care Agreement (Integraal Zorgakkoord, IZA) aim to support older people in living independently at home for as long as possible. However, professionals often lack a shared conceptual framework and practical tools to assess and support FI in a timely and person-centred way. The aim of this thesis is to improve the understanding of FI in older people and to develop tools that support healthcare professionals in optimising and maintaining FI. The thesis combines conceptual development, empirical validation, cluster analysis, tool development, and implementation research, contributing to more proactive and integrated care. Chapter 2 addresses the conceptual ambiguity surrounding FI through a scoping review and expert consultation. Despite its frequent use, no shared definition was identified. This chapter introduces a working definition of FI as functioning physically safe and independently from others, within one’s personal context. Four interrelated domains are identified: physical capacity, coping, empowerment, and health literacy. These domains are visualised in a conceptual model to support shared understanding and interdisciplinary dialogue. Chapter 3 focuses on operationalising FI through the development and validation of the Core Outcome Set for Functional Independence (COSFI). COSFI enables consistent, multidimensional assessment across disciplines and offers a person-centred alternative to traditional frailty screening. Psychometric analyses show that COSFI predicts FI with 68% accuracy, with coping and health literacy adding predictive value beyond physical capacity alone. To address heterogeneity among older people, Chapter 4 identifies four distinct FI profiles using cluster analysis: Performers – Well-informed, Performers – Achievers, Reliant – Good Copers, and Reliant – Receivers. These profiles reflect meaningful variation in physical, behavioural, and contextual characteristics. Building on these findings, Chapter 5 introduces the Decision Support Tool for Functional Independence (DST-FI). The DST-FI supports professional judgement by guiding users through three steps: measuring FI with COSFI, allocating individuals to an FI profile, and generating person-centred care recommendations. Initial evaluation demonstrates acceptable reliability and clinical validity. Chapter 6 examines the feasibility and perceived value of the DST-FI in primary care. Older people experienced the tool as relevant and empowering, while professionals valued the structured guidance and shared language. Barriers included time constraints, unclear ownership, and challenges in preventive use. Chapter 7 explores implementation using the Consolidated Framework for Implementation Research (CFIR). Key facilitators included alignment with policy goals and interprofessional collaboration, while barriers related to context, time, and stakeholder ownership. Overall, this thesis advances the conceptualisation of Functional Independence and provides practical tools to support healthcare professionals in promoting and maintaining FI in older people.