Older people with social care needs and multiple long-term conditions

In November 2015, the National Institute for Health and Care Excellence (NICE) in the UK published a guideline on care and support for older people with social care needs and multiple long-term conditions. The guideline recommends that care should be integrated and person-centred, while at present “some people are still being treated as a collection of conditions or symptoms, rather than as a whole person”. NICE calls for a designated care coordinator who would serve as the older person’s first point of contact as well as communicate with all health and social care services, including those provided by non-governmental organizations. Moreover, care should be supported by community-based multidisciplinary teams, which might include “a community pharmacist, physiotherapist or occupational therapist, a mental health social worker or psychiatrist, and a community-based services liaison worker”. The guideline also calls for health and social care providers to support the person with respect in ...

I’m Still Me: A Narrative For Coordinated Support For Older People

Care coordination should be a means to achieving specific outcomes, rather than an end in itself. In turn, it is important that these outcomes reflect what patients want. In December 2014, National Voices, Age UK and UCLPartners jointly published I’m Still Me, a document that focuses on what older people consider to be the most important outcomes of coordinated support. The report is based on a variety of research methods, including 74 semi-structured interviews with older individuals. The research identifies a number of outcomes which are key to older people, such as maintaining their independence and retaining their own choice in decision making. I’m Still Me also includes a series of ‘I statements’ that summarise what older people have said they want their support to look like. For example: "I am supported to be independent"; “I can do activities that are important to me”; “I can maintain social ...

Personalised Integrated Care Programme

All too often older people living with long-term conditions do not have a sustainable care plan to keep them out of the hospital. Launched in Cornwall in 2013, Age UK’s Personalised Integrated Care programme uses risk stratification to both identify those older people who are at risk of recurring hospital admissions and provide a combination of medical and non-medical support. This support starts with a 'guided conversation' between the older person and an Age UK Personal Independence Co-ordinator. In this conversation they outline the goals that the older person identifies as most important to him or her and they draw a care plan which will include a combination of voluntary, health and care organisations. Following this, an Age UK volunteer is matched with the older person, both to help in achieving his or her goals, but also to encourage them to be more independent in managing their own care ...

Enhancing Connectedness Through Peer Training for Community-Dwelling Older People: A Person Centred Approach

Social interaction and connectedness is important to the mental health and wellbeing of older people. The aim of this research study was to facilitate and increase opportunities for social connectedness for older people living in regional areas through the use of technology training. Weekly technology training sessions were conducted at a Seniors Citizen's Club with a peer trainer (an experienced, retired computer teacher) and sessions were attended not only by the six study participants, but also by other club members, with up to 15 club members participating in sessions. Data analysis involved all documents generated by the project, including the individual interviews, researcher observations of training sessions, reports from the peer trainer and weekly diaries maintained by participants. Findings demonstrated that computer training at the Senior Citizens Club helped participants build group cohesion and to form tiered connections with partners, family, and friends with whom they no longer live ...

Diversity Conceptual Model for aged care: Person-centred and difference-oriented and connective with a focus on benefit, disadvantage and equity

AIM:

This project aimed to develop a Diversity Conceptual Model to support the aged care sector to identify diversity characteristics and associated benefits and disadvantages in order to consider greater equity in policy and practice.

METHODS:

A multi-method approach was used to develop the Diversity Conceptual Model using a literature review, organisation-wide consultation using a questionnaire, focus groups and interviews with key stakeholders.

RESULTS:

A Diversity Conceptual Model was developed as a visual 'tool', made up of numerous components, with a focus on diversity characteristics that may be creating benefits and disadvantages for a consumer to participate in their health care. Continuous quality improvements and equity are presented as essential overarching components of the Model.

CONCLUSION:

The Diversity Conceptual Model has many potential applications for aged care. The author proposes that its wider adoption would increase confidence, skills and knowledge, enabling the aged care sector to influence greater equity in ...

SUSTAIN Project: Sustainable tailored integrated care for older people in Europe.

SUSTAIN is a cross-European research project and stands for sustainable tailored integrated care for older people in Europe. It aims to concretely improve the way care services for older adults are organised and delivered across Europe, and especially for those who have multiple health and social care needs. 

The project started from the observation that in all European countries, care for older people is often poorly coordinated. This prevents care from adequately meeting the needs of older adults, and it shows that quality of care and outcomes could be much improved. 

Concretely, the project will:

• Analyse the 14 care services by gathering data and by interviewing several persons who are involved (practitioners, users, policy makers, health insurers etc.).
• With a group of organisations (associations, groups, etc.) at local level, design and implement a set of improvements of the care service, with regards to key principles and values for quality of ...

SUSTAIN: Sustainable tailored integrated care for older people in Europe

Problem: The project started from their observation that in all European countries, care for older people is often poorly coordinated. This prevents care from adequately meeting the needs of older adults, and it shows that quality of care and outcomes could be much improved.

Solutions:  SUSTAIN will in particular aim to support and improve what we call ‘integrated care’. By a better ‘integration’ of care, it means that: care for older people is better organised, and professionals coordinate the care they deliver; older persons’ health and social care needs are well assessed; care services listen carefully to older persons and informal carers, seek to involve them in the decisions affecting them and deliver care in line with their needs and preferences as much as they can (‘person-centred care’); professionals from different disciplines (prevention, healthcare, social care) are included in the care team, and different types of support are offered (including ...

Community-based social innovations to support older people: Pre-call announcement to identify case study sites in middle-income countries

The World Health Organization Centre for Health Development Kobe and RAND Europe would like to invite pre-applications for case-studies on community-based social innovations (CBSIs) that support older people in middle-income countries (MICs). A full call for applications will be made at the beginning of November 2016. At this stage we would like to gauge interest and identify the range of CBSIs potentially eligible and to raise awareness about the study.

Know more...

Better transfers of care for older people: How to improve transitions from hospital

Drawing on the findings from recent reports by The King’s Fund, Healthwatch England, the National Audit Office, the Care Quality Commission and the Parliamentary and Health Services Ombudsman (PHSO), this event will explore new ways of ensuring older people experience a safe, appropriate and timely discharge that is right for them and their health needs. In this event you will discover good practice examples in health, local government, social care, community services and housing and learn how services can plan ahead across their whole populations to proactively manage those most at risk.

Meet Integrated Care Pioneers in Edinburgh, Manchester and Wrexham!

Study tours offer a unique opportunity to meet integrated care pioneers in their natural environment and to experience and learn about integrated care practices from national and regional innovations. They are designed to support clinicians, managers and policy-makers with an interest and responsibility in the successful adoption of integrated care in policy and practice. Designed to be live case studies, the study visits offer the possibility to discuss regional and country-level strategies with the responsible decision makers, assess the barriers, facilitators and key drivers for integrated care at a regional and local level and reflect upon the transferability of lessons learned in moderated discussions and workshops.

The ICIC17 Three Country Study Tour will visit Scotland, England and Wales and seeks to examine the leadership and management of integrated care in these regions. Sessions will focus on the development of new models and approaches to care for older people with complex ...

SUSTAIN goes live: video-interviews with representatives from the sites

SUSTAIN is a cross-European research project and stands for sustainable tailored integrated care for older people in Europe. The project aims to concretely improve the way care services for older adults are organised and delivered across Europe, and especially for those who have multiple health and social care needs.SUSTAIN is a cross-European project with thirteen partners from nine countries. SUSTAIN is working with fourteen initiatives in seven participating countries. These initiatives aim to achieve integrated care for older people living at home and SUSTAIN will support them in further improving this care.

The project consortium has produced a series of video-interviews aimed at sharing the early experience of professionals directly involved in the implementation of the project within the SUSTAIN sites. In particular, we aimed at getting views and opinions on motivations, goals and objectives, implementation challenges and cross-countries exchenges between the SUSTAIN sites.

The first round of videos ...

SUSTAIN goes live: video-interviews with representatives from the sites

SUSTAIN is a cross-European research project and stands for sustainable tailored integrated care for older people in Europe. The project aims to concretely improve the way care services for older adults are organised and delivered across Europe, and especially for those who have multiple health and social care needs.SUSTAIN is a cross-European project with thirteen partners from nine countries. SUSTAIN is working with fourteen initiatives in seven participating countries. These initiatives aim to achieve integrated care for older people living at home and SUSTAIN will support them in further improving this care.

The project consortium has produced a series of video-interviews aimed at sharing the early experience of professionals directly involved in the implementation of the project within the SUSTAIN sites. In particular, we aimed at getting views and opinions on motivations, goals and objectives, implementation challenges and cross-countries exchenges between the SUSTAIN sites.

The first round of videos ...

WEBINAR Integrated Care Matters Series 2- Preventing and Managing Frailty

The International Foundation for Integrated Care is delighted to introduce the 2nd series of webinars on people-centred integrated care in practice. This series will have a particular focus on active and healthy ageing and preventing and managing frailty. The webinars will be hosted by IFIC Scotland in collaboration with the University of the West of Scotland, the Institute of Research and Innovation in Social Services, and the Health and Social Care Alliance.  Each monthly webinar will feature health and care practitioners from Scotland in conversation with colleagues from across the World and with insights from people who currently use health and social care support. All of our ‘Home and Away’ presenters have experience of implementing people-centred integrated care for older people and will offer practical tips and peer support as part of IFIC’s global community of practice. Each webinar will extend IFIC’s on-line knowledge tree by collating information ...

Enhanced health in care homes: Lessons from good practice on embedding integrated care

This conference is for care home providers, health care providers, and commissioners who are thinking through how to improve the quality of life and health care for people living in care homes. It will share lessons from the six vanguards for enhanced health in care homes, and other local examples of good practice, to enable attendees to learn from initiatives that have worked well and can be replicated across the country.

Enhanced health in care homes: learning from experiences so far

Enhanced health in care homes can be achieved by close co-ordination between care homes and the range of health services required to meet the needs of older people living in the care homes. When these services work closely together – for example, through regular GP visits to care homes and regular comprehensive assessments – they can actively promote good health rather than just reacting to ill health.

Achieving Integrated Care for Older People: Shuffling the Deckchairs or Making the System Watertight For the Future?

Integrated care has been recognised as a key initiative to resolve the issues surrounding care for older people living with multi-morbidity. Multiple strategies and policies have been implemented to increase coordination of care globally however, evidence of effectiveness remains mixed. The reasons for this are complex and multifactorial, yet many strategies deal with parts of the problem rather than taking a whole systems view with the older person clearly at the centre. 

Integrated care for older people (ICOPE) implementation framework: guidance for systems and services

Alongside supporting community-level services, the Integrated Care for Older People (ICOPE) approach helps broader health and social care systems effectively respond to the diverse and complex needs of older people. The ICOPE Implementation Framework provides guidance for policy makers and programme managers to concretely assess and measure the capacity of services and systems to deliver integrated care at the community level.

The ICOPE Implementation Framework provides a score card to help assess the overall capacity of health and social care services and systems to deliver integrated care in community settings and support the development of ICOPE implementation action plans. There are 19 actions needed to implement ICOPE on the services level (meso) and systems level (macro). The scoring process provides an evidence-based means of highlighting areas for improvement as well as establishing concrete measures of future improvements.

Mobile Health for Ageing (mAgeing)

Health information, advice, and reminders delivered through mobile phones can encourage healthy behaviors and help older people to improve and maintain their intrinsic capacity. The WHO mobile health for Ageing (mAgeing) programme has been developed as one of the tools to support the implementation of WHO guidelines on community-level interventions to manage declines in intrinsic capacity – also known as the ICOPE Guidelines. The mAgeing programme can support routine care offered by health care professionals by supporting self-care and self-management.

The newly published Handbook helps countries develop, run, monitor, and evaluate the mAgeing programme within their own contexts, using basic technology common to most mobile phones.

Integrated care for older people (ICOPE): guidance for person-centred assessment and pathways in primary care

The ICOPE guidance for person-centred assessment and pathways in primary care (ICOPE Handbook) helps community health and care workers put the recommendations outlined in the ICOPE Guidelines into practice. The Handbook assists with setting person-centred goals, screening for loss in a range of domains of intrinsic capacity and assessing health and social care needs to develop a personalised care plan. The care plan may include multiple interventions to manage declines in intrinsic capacity, provide social care and support, support self-management and support caregivers. The domains of intrinsic capacity include cognitive decline, limited mobility, malnutrition, visual impairment, hearing loss and depressive symptoms.

Ghana country assessment report on ageing and health

Ghana, like many other countries, is experiencing a demographic transition with its ageing population. To provide reliable evidence for policy-making in ageing and health, this assessment report is prepared to identify priority issues on ageing in Ghana. By reviewing evidence from the WHO Study on global AGEing and adult health (SAGE) in Ghana and other sources, this document reveals the health status of older people in Ghana as well as the health systems response and policies relevant to ageing. The report also proposed 5 priorities relating to the prevention, treatment and care needs of older people in Ghana.

China country assessment report on ageing and health

China is ageing much faster than other low- and middle-income countries. The proportion of the population aged 60 years and over will increase from 12.4% in 2010 to 28% in 2040. Also women outlive men, and populations in rural areas have higher proportions of older people.
Therefore, social and economic transitions are changing traditional care arrangements for older people in China. So, a health transition from communicable to noncommunicable disease is well under way in China.

WHO launches an innovative package of tools to support person-centred and integrated care for older people

On the International Day of the Older Person (1st October) the World Health Organization (WHO) released a package of tools to support the implementation of the Integrated Care for Older People (ICOPE) approach.

ICOPE, based on the WHO Framework on integrated people-centred health services, has been developed in the context of populations around the world ageing rapidly. It enables health and long-term care systems-and the services within them-to respond optimally to the unique, varied and often complex needs of older people.

The package of tools includes: the ICOPE Implementation Framework (guidance for policy makers and programme managers to assess and measure the capacity of services and systems to deliver integrated care at the community level); the ICOPE Handbook, which describes practical care pathways to detect declines in intrinsic capacity and develop personalised care plans; and the ICOPE handbook App, which helps implement ICOPE in community care settings.

Access ICOPE tools ...

Integrated Care for Older People (ICOPE)

How to adapt person-centered health services to ageing populations?

Every older person, everywhere, should have access to high quality and person-centred health services. That's why the World Health Organization has published guidelines on Integrated Care for Older People.

Learn more here: https://www.who.int/ageing/health-systems/icope/en/ and here: https://www.who.int/ageing/publications/guidelines-icope/en/

Populations around the world are rapidly ageing. It will increase demand for primary health care and long-term care, require a larger and better trained health workforce and intensify the need for age-friendly environments. These investments can enable the many contributions of older people – whether it be within their family, to their local community or to society more broadly. Universal health coverage for older people means quality health services that are integrated and person-centered.

Societies that adapt to this changing demographic and invest in Healthy Ageing can enable individuals to live both longer and healthier lives and for societies to ...

Multiple Perspectives Analysis of the Implementation of an Integrated Care Model for Older Adults in Quebec

Integrated care models for older adults are increasingly utilised in healthcare systems to overcome fragmentations. Several groups of stakeholders are involved in the implementation of integrated care. The aim of this study is to identify the main concerns, convergences and divergences in perspectives of stakeholders involved in the implementation of a centralised system-wide integrated care model for older adults in Quebec.

Exploring improvement plans of fourteen European integrated care sites for older people with complex needs

Integrated care programmes are increasingly being put in place to provide care to older people living at home. However, knowledge about further improving integrated care is limited. In fourteen integrated care sites in Europe, plans to improve existing ways of working were designed, implemented and evaluated to enlarge the understanding of what works and with what outcomes when improving integrated care. This paper provides insight into the existing ways that the sites were working with respect to integrated care, their perceived difficulties and their plans for working towards improvement. 

A model of integrated care of residents with dementia - A case of innovation in long-term with accomodation in Slovenia

In all parts of the world, the number of people with dementia is on the increase and dementia is becoming more and more of a challenge for social work, too. In the countries with well-developed care for older people, dementia is part of longterm care; therefore, it is essential to develop new methods of care also in the homes for older people that provide long-term care. Among the innovative forms of care, there is a model of integrated care, based on social work concepts. This model is presented through the case of care for the residents with dementia in one of the old people’s homes in Slovenia. The integrated care of residents with dementia puts an individual at the centre of care provided by the experts employed there. The resident of old people’s home and an expert there create a
partnership in which they seek out solutions stemming ...

Communication and Coordination Processes Supporting Integrated Transitional Care: Australian Healthcare Practitioners’ Perspectives

Although a large body of research has identified effective models of transitional care, questions remain about the optimal translation of this knowledge into practice. In Australia, the introduction of a model of consumer-directed care uniquely challenges the practice of integrated care transitions for older adults. This study aimed to identify strengths and weaknesses in transitional care for older adults in an Australian setting by describing healthcare practitioners’ experiences of care provision.

Webinar: Promoting Visibility and Inclusion: Protecting Older Persons and People with Disabilities during the COVID-19 Pandemic

The COVID-19 pandemic is intensifying inequalities and producing new threats for older persons and persons with disabilities. COVID-19 case fatality rates suggest a notable increase in risk after age 60, with progressively worse outcomes for those over 70 and over 80 years. Likewise, people with disabilities are among the hardest hit. 

To raise awareness and ensure that the UN regional system is equipped to help governments  guarantee the equal rights of older people and people with disabilities to access healthcare and lifesaving procedures during the pandemic, UNFPA, WHO and UNDCO, in coordination with the United Nations European Regional Issue Based Coalition on Health, will convene a one-hour webinar focused on supporting UNCTs in their work to advocate for greater attention to the specific needs of vulnerable persons. Panelists from civil society organizations actively engaged with the UN system will offer views on scaling up immediate responses while making COVID19 a ...

Framework Implementation of the inspire ICOPE-Care program in collaboration with the World Health Organization (WHO) in the Occitania Region

Limiting the number of dependent older people in coming years will be a major economic and human challenge. In response, the World Health Organization (WHO) has developed the «Integrated Care for Older People (ICOPE)» approach. The aim of the ICOPE program is to enable as many people as possible to age in good health. To reach this objective, the WHO proposes to follow the trajectory of an individual’s intrinsic capacity, which is the composite of all their physical and mental capacities and comprised of multiple domains including mobility, cognition, vitality / nutrition, psychological state, vision, hearing.

Implementation of the Integrated Care of Older People (ICOPE) App in Primary Care: New Technologies in Geriatric Care During Quarantine of COVID-19 and Beyond

The COVID-19 pandemic due to a novel coronavirus (SARS-CoV-2) in December 2019 has rapidly spread worldwide. The mortality rate is about 2.3% in general population, with high human-to-human transmission of 0.41 (credible interval [0.27, 0.55]), and nasopharyngeal asymptomatic carriers act as vectors within the population. The World Health Organization (WHO) declared the pandemic on March 2020, and established objectives and action plan. First, WHO aimed at limiting the transmission of SARS-CoV-2, which required large isolation actions (country borders lockdown and individual quarantine). Second, WHO aimed at guiding and supporting the different health care systems across countries. Finally, developing therapeutic interventions appeared as a global priority as available evidence were still scarce. More than 860 clinical trials are ongoing worldwide.

Integrated delivery and continuity of care in times of crisis

Ensuring continuity of care in response to the Covid-19 crisis has been a key issue for public health and social care services across Europe. Whilst the implementation of local partnerships for integrated care delivery have been identified as a success factor, in many cases the reality on the ground has been one of a fragmented market. One, where providers of home care, residential care and supported living have been under pressure due to the lack of protective equipment, the fear of infection, and a reduction in the number of professionals.

Still a fragmented un-resourced system

In light of the Covid-19 crisis, care services have been reaping a bitter harvest of years of failure to invest adequately in public health and social care systems. While older people’s care services have been affected across Europe, the situation has been particularly difficult in two countries: the UK and Spain.

In Spain, the ...

Supporting older people in remote areas in a post COVID-19 time

The COVID-19 pandemic, like other disasters, undermines older people´s capacity and chances of survival as a result especially of emergency induced mental health and psychological problems, and the breakdown in services for preventing and treating chronic conditions and for providing social support. Furthermore, maintaining relationships is often identified by older people as central to their wellbeing, but social distancing has transformed the lives of everyone in society and has changed relationships and personal contact as well. Here, we set out how the COVID-19 pandemic affects older people in remote areas specifically.

Policy Brief: The Impact of COVID-19 on older persons

The COVID-19 pandemic is causing untold fear and suffering for older people across the world. As the virus spreads rapidly to developing countries, likely overwhelming health and social protection systems, the mortality rate for older persons could climb even higher. Efforts to protect older persons should not overlook the many variations within this category, their incredible resilience and positivity, and the multiple roles they have in society, including as caregivers, volunteers and community leaders.

COVID-19 recovery is an opportunity to set the stage for a more inclusive, equitable and age-friendly society.

COVID-19: General recommendations for the care of older persons from a human rights perspective

Older people may be more likely to experience complications during the COVID-19 pandemic, so this paper provides recommendations for the care of this social group from a human rights perspective, which can be applied in the home, community and long-term care facilities. These recommendations were drawn up on the basis of good practices in countries in the Latin American and Caribbean region and beyond.

COVID-19 and Older Persons: A Defining Moment for an Informed, Inclusive and Targeted Response

As the world grapples with an unparalleled health crisis, POLICY BRIEF NO68 older persons have become one of its more visible victims. The pandemic spreads among persons of all ages and conditions, yet available evidence indicates that older persons and those with underlying medical conditions are at a higher risk of serious illness and death from the COVID-19 disease. This brief has presented the distinct situation of older persons during the COVID-19 pandemic. It highlights how older persons encounter specifc challenges that need to be understood and integrated into policy measures related to COVID-19. 

Different Contexts, Similar Challenges. SUSTAIN’s Experiences with Improving Integrated Care in Europe

SUSTAIN stands for ‘Sustainable Tailored Integrated Care for Older People in Europe’ (www.sustain-eu.org). The SUSTAIN-project was carried out between 2015 and 2019 by thirteen partners from eight European countries: Austria, Belgium, Estonia, Germany, Norway, Spain, the Netherlands, and the United Kingdom.

The SUSTAIN project was designed to support the development of integrated care for older people living at home with health and social care needs. Its objectives were twofold: 1. To support and monitor improvements to established integrated care initiatives and 2. To contribute to the adoption and application of such improvements to other health and social care systems and regions in Europe.

With the exception of partners in Belgium, all SUSTAIN researchers selected two integrated care initiatives in their countries for participation in the SUSTAIN-project. The different integrated care initiatives were committed to improving their current practices by working towards more person-centered, prevention-oriented, safe ...

Integrated older people care and advanced practice nursing: an evidence-based review.

The world's population is aging rapidly. This is a fact, and the demand for services adapted to this new reality is increasingly necessary. The World Health Organization has proposed an integrative strategy centered on people. Here present a systematic review of strategies that address the care of older adults with the integrated care-centered approach to people.

Integrated care and platform solutions for a better provision of health and care service

This thematic workshop is the opportunity to discuss solutions of integrated care concepts rolled out by ICT-supported primary and secondary care interventions for older people living at home. Focus will be set onto the implementation challenges and the lessons learned from projects throughout EIP on AHA Reference Sites such as the Oberbergischer Kreis, the Portuguese Amadora as well as by the multi-stakeholder open platform concept rolled out in the EU-H2020 SHAPES project.

Telemonitoring and continuity of care for older subjects: comparing experience an identifying common solutions

The COVID19 pandemic highlighted some structural – organizational and cultural – limitations of our dominant model of (health)care. One of these is the need to identify and adopt newer instruments for the continuity of care for the large number of patients with chronic disease who live in low-density population areas  (200 million or 27% of EU population) and experience inequality to access (health)care because of the distance between community and healthcare structures. Notably, the onset of multimorbidity occurs 10–15 years earlier in people living in the most deprived areas compared with the most a?uent.

The Workshop aims at facilitating knowledge acquisition (including existing Projects and adopted solutions) and at fostering collaboration and standardization of best practice, including health literacy and patients and caregivers empowerment, in order to impact on the adoption of innovative digital solutions able to boost people's health and quality of life and enable more ...

Exploring the Team Climate of Health and Social Care Professionals Implementing Integrated Care for Older People in Europe

Team climate describes shared perceptions of organisational policies, practices and procedures. A positive team climate has been linked to better interprofessional collaboration and quality of care. Most studies examine team climate within health or social care organisations. This study uniquely explores the team climate of integrated health and social care teams implementing integrated care initiatives for older people in thirteen sites across seven European countries, and examines the factors which contribute to the development of team climate.

ValueCare: Cork/Kerry Pilot Site

Collaborative Experience Success Stories in Integrated Care of Older People: A Narrative Analysis

With the increasing differentiation of organisations involved in the pursuit of public health, there is also a growing need for inter?organisational integration. Starting from the concepts of differentiation and integration, this article is attempting a theoretical reconstruction based on published research on inter?organisational integration in public health and related welfare services.

The call for integrated care has been induced by demographic change, increased fragmentation of the welfare sector and increased demand for technically and more expensive care solutions. There is a wide variety of strategies and initiatives to improve care continuity and coordination for people with chronic diseases, not least for older people with complex care needs who require care from multiple providers.

Inter-organisational collaboration is crucial in the care of older people, as is the development of integrated care. Storytelling in organisations is one way of understanding how to achieve successful collaboration. This article provides insights into ...

Leadership in integrated care networks: A literature review and opportunities for future research

This article reviews research on leadership in integrated care networks. It is timely as scholars and policy makers regard integrated care as a key part in reforming healthcare systems to cope with demographic aging, the rising prevalence of chronic diseases and the growing demand for long-term care.

In many countries, elderly patients with chronic conditions require a web of services delivered by several providers collaborating in inter-organisational networks. In view of their global importance, it is surprising how little we know how these networks are led. Like traditional organisations, networks require leadership to function effectively. This paper reviews central characteristics of leadership in integrated care networks and proposes opportunities for future research.

In this article, 73 studies published in the main academic journals are analyzed. This article consolidates the research on means, practices, activities and results of leadership, covering the levels of analysis of networks, policies and organizations.

Building a Digital Bridge to Support Patient-Centered Care Transitions From Hospital to Home for Older Adults With Complex Care Needs: Protocol for a Co-Design, Implementation, and Evaluation Study

Older adults with multimorbidity and complex care needs (CCN) are among those most likely to experience frequent care transitions between settings, particularly from hospital to home. Transition periods mark vulnerable moments in care for individuals with CCN. Poor communication and incomplete information transfer between clinicians and organizations involved in the transition from hospital to home can impede access to needed support and resources. Establishing digitally supported communication that enables person-centered care and supported self-management may offer significant advantages as we support older adults with CCN transitioning from hospital to home.

This protocol outlines the plan for the development, implementation, and evaluation of a Digital Bridge co-designed to support person-centered health care transitions for older adults with CCN. The Digital Bridge builds on the foundation of two validated technologies: Care Connector, designed to improve interprofessional communication in hospital, and the electronic Patient-Reported Outcomes (ePRO) tool, designed to support goal-oriented care planning ...

Effect of an integrated care model for pre-frail and frail older people living in community

The objective of this article is to evaluate the effect of an integrated care model for pre-frail and frail community-dwelling older people.

Medical and Old-Age Care Integration Model and Implementation of the Integrated Care of Older People (ICOPE) in China: Opportunities and Challenges

The demand for healthy old-age care is growing rapidly in China. The traditional old-age care model can no longer meet elderly patients’ demands for medical care and old-age care. To promote the development of medical care-integrated old-age care, a solution covering multiple aspects is necessary. In the context of the global development of healthy aging, China recently issued many policies to integrate old-age care with medical care, establishing protection for a large number of disabled elderly people. The Integrated Care of Older People (ICOPE) project is an international program developed by the World Health Organization. This paper reviews China’s medical and old-age care integration model and the opportunities and challenges in implementing the ICOPE in the context of healthy aging in China.

Implementing Integrated Care in Practice – Learning from MDTs Driving the Integrated Care Programme for Older Persons in Ireland

The importance of multidisciplinary teams (MDTs) as critical implementation drivers emerged from this case study conducted with three pioneer sites implementing integrated care for older persons in Ireland as part of the Integrated Care Programme for Older Persons (ICPOP).

The study describes the practices of MDTs learning to deliver integrated care in service delivery settings, including the framework, resourcing, strategies, challenges and barriers they encounter.

Measuring Older Peoples’ Experiences of Person-Centred Coordinated Care: Experience and Methodological Reflections from Applying a Patient Reported Experience Measure in SUSTAIN

While several evaluation studies on (cost-)effectiveness of integrated care have been conducted in recent years, more insight is deemed necessary into integrated care from the perspective of service users.

In the context of a European project on integrated care for older people living at home (SUSTAIN), this paper shares the experience and methodological reflections from applying a Patient Reported Experience Measure (PREM) on person-centred coordinated care -the P3CEQ- among this population.

Intrinsic Capacity predicts adverse outcomes using Integrated Care for Older People screening tool in a senior community in Beijing

The World Health Organization (WHO) introduced the concept of intrinsic capacity in order to create a multidimensional model to maintain individual's functional ability. Intrinsic capacity is the composite of all the physical and mental capacities that an individual can draw on at any point in time, and represents the amount of resources one can tap into during his life(WHO, 2015). By interacting with the surrounding environment, intrinsic capacity determines functional ability largely. Considering and organizing the retrieved evidence, five domains are proposed to define the intrinsic capacity: cognition, locomotion, vitality, sensory, and psychosocial, each of which is composed of subdomains(Cesari et al., 2018). In 2017, the WHO published Integrated Care for Older People (ICOPE): Guidelines on community-level interventions to manage declines in intrinsic capacity, and highlighted the importance of focusing on intrinsic capacity to establish effective interventions(WHO, 2017). In 2019, Guidance for person-centered assessment and pathways ...

Designing a person-centred integrated care programme for people with complex chronic conditions: a case study from Catalonia

The prevalence of people with complex chronic conditions is increasing. This population’s high social and health needs require person-centred integrated approaches to care. We developed an evidence-based integrated care programme tailored to high-need patients combining input from patients, caregivers, and healthcare and social care professionals. Patients’ and caregivers’ main priorities were to ensure (a) comprehension of information provided by healthcare professionals; (b) coordination between patients, caregivers, and professionals; (c) access to social services; (d) support to caregivers in managing situations; (e) perceived support throughout the healthcare process; (f) home care, when available; and (d) a patient-centred approach

Developing an interprofessional people-centred care model for home-living older people with multimorbidities in a primary care health centre: A community-based study

The ageing population with multiple conditions and complex health needs has forced healthcare systems to rethink the optimal way of delivering services. Instead of trying to manage numerous diseases in a siloed approach, the emphasis should be on people-centred practice, in which healthcare services are tailored to people's needs and provided in partnership with them. 

The aim was to develop an interprofessional people-centred care model (PCCM), including the contribution of a clinically trained pharmacist for home-living multimorbid older people in primary care.

Models of integrated care for older people with frailty: a horizon scanning review

Frailty, a multifaceted geriatric condition, is an emerging global health problem. Integrated care models designed to meet the complex needs of the older people with frailty are required. Early identification of innovative models may inform policymakers and other stakeholders of service delivery alternatives they can introduce and locally adapt so as to tackle system fragmentation and lack of coordination. This study used horizon scanning methodologies to systematically search for, prioritise and assess new integrated care models for older people with frailty and investigated experts’ views on barriers and facilitators to the adoption of horizon scanning in health services research.

Factors and Mechanism Influencing Client Experience of Residential Integrated Health and Social Care for Older People: A Qualitative Model in Chinese Institutional Settings

An emerging service delivery model of integrating health and social care for older people has been actively promoted by the Chinese government since 2016, but the client experience and influencing mechanism still remain unclear. Methods: this study adopts a qualitative methodology to delve deeper into the factors and mechanism shaping the client experience of residential integrated health and social care for older people in the Chinese context, so as to understand the experiences of older residents during the whole process of receiving integrated care services, and on this basis, put forward suggestions for the improvement of a high-quality aged care service system. We coded and analyzed the in-depth interview data of twenty older adults and six staff members from June 2019 to February 2020, recruited from six institutions in Changsha, one of the ninety pilot cities for integrated health and social care in China. Results: the findings showed that the ...

What are the Clinical and Social Outcomes of Integrated Care for Older People? A Qualitative Systematic Review

Older people with multiple chronic conditions have most to gain from successful integrated care models but there is a need to understand current evidence of outcomes for older people.

8 Elements of person-centred care of older people in primary healthcare: a systematic literature review with thematic analysis

Higher life expectancy in the ageing population and, consequently, anincrease in the older population bring additional challenges for healthcare pro-viders, especially in primary healthcare. The person-centred care of older people isdefined as an approach that puts older people at the centre of care and recognizesthe importance of their needs. The chapter aims to identify the key elements of per-son-centred care for older people, in primary healthcare.

Diagnostic performance analysis of the ICOPE screening tool for identifying decline in intrinsic capacity

Intrinsic capacity (IC) is a comprehensive indicator of an individual's positive attributes. The World Health Organization (WHO) recommends a two-step approach to assess IC decline among older people. The first step involved using the Integrated Care for Older People (ICOPE) screening tool to identify potential issues, and the second step involved using detailed assessments for confirmation. This study aimed to assess the diagnostic performance of ICOPE screening tool as a simple preliminary screening to identify IC decline among community-dwelling older adults, which was rarely reported in China.

Person-centred long-term care for older persons: a new Lancet Commission

The UN declared 2021–30 to be the Decade of Healthy Ageing, and efforts are being made to maximise the functional ability of people over their life course. Yet older people are marginalised and perceived as a burden, particularly those with ongoing loss in capacity. Nowhere is this more conspicuous than in the context of long-term care (LTC) worldwide, where older people in some settings encounter a loss of independence and other violations of their human rights. Such experiences can range from deprivation of liberty and loss of legal capacity and consent to coerced institutionalisation, exposure to abuse, neglect,and disrespect, and persistent use of restraints. 

Integrated Care for Older People: Theories and Practices

As the first Chinese monograph to explicitly connect the “Yiyang Jiehe” with “integrated care for older people”, this book presents readers with a thorough overview of integrated care for older people, from theoretical content, management tools, to practices in China and international learning.