Table 1 Characteristics of included integrated care programs (abbreviation definitions below)
Country | Program name | Setting + target group | Goal of program | Elements of integrated care addressed in program | ||
|---|---|---|---|---|---|---|
Interdisciplinary | Comprehensive | Person-centred | ||||
United States | People aged ≥70 years from an urban community who were cognitively unimpaired and reported some functional difficulties. | Reduce functional difficulties by modifying behavioural and environmental contributors to functional decline. | OT and PT performed home visits and telephone consultations, and together coordinated their activities. | Program targeted participants’ physical functioning, behaviour and physical environment. | Intervention focused on problems identified and prioritised by older people. | |
United States | Low-income people aged ≥65 years from an urban community who were cognitively unimpaired, and who reported some functional difficulties. | Reduce the impact of disability among low income adults by addressing individual abilities and the home environment. | OT and RN performed home visits, and licensed handyman performed home modifications. | Program targeted participants’ physical health and functioning, psychological health, behaviour and physical environment. | Older people were involved in identifying and prioritising problem areas, and developing action plans. | |
United States | Older people aged ≥65 years from an urban community who were enrolled in participating primary care practices, and who were at high risk of heavily using health services during the following year. | To first improve patients’ quality of care and physicians’ satisfaction with the quality of care, which would later improve patients’ quality of life and efficiency in the use of resources for older adults with multimorbidity. | RN collaborated with the GP and primary care office staff, and coordinated the activities of all care providers involved. | Program included a CGA of the medical, functional, cognitive, affective, psychosocial, nutritional, and environmental status of older people. | Older people were involved in prioritizing care needs, and care plans were adjusted according to their priorities and preferences. | |
United States | Older people aged ≥65 years who were cognitively unimpaired and at risk for functional decline after acute illness or hospitalization, but who had the potential for maintaining or improving their functioning. | Improve participants’ health outcomes, functional status and service use; and increase their likelihood of remaining at home. | Home care agency reorganized staff into multidisciplinary teams consisting of an RN, OT, PT and HHAs. | Reorientation of home care teams’ focus from primarily treating diseases and “taking care of” patients to that of working together to maximize functioning and comfort. | Goals and the process of reaching them was established based on input from and agreement between the patient, the family and home care staff. | |
The Netherlands | Frail older people ≥70 years from an urban community who were registered with participating general practices. | Improve quality of life and reduce functional decline, institutionalization, and hospitalization among frail older people living in the community. | Multidisciplinary team consisted of a GP, CCRN, gerontological social worker, elderly care physician, and a pharmacist. CCRN or social worker functioned as case managers. | Program targeted participants’ goals and needs on the domains of health and wellbeing | Case manager supported participants with goal setting and self-management by means of home-visits and telephone contacts. | |
The Netherlands | People aged ≥75 years from a semi-rural community who were registered with participating general practices. | Support older adults to age in place and improve health outcomes. Also improve quality of care and reduce service use and costs. | Multidisciplinary team consisted of GP, CCRN, social worker and elderly care physician. For complex and frail participants, the nurse or social worker acted as case manager. | Program took into account all aspects of participants’ functioning and disability, along with social and environmental aspects of their lives. | Older people were involved in identifying and prioritizing care needs, and the case manager helped navigate them through the processes of organizing the appropriate care and support. | |
The Netherlands | People aged ≥70 years at increased risk of functional decline who were registered with participating general practices. | Prevent or delay functional decline and disability. | Intervention was delivered by CCRN and GP. CCRN collaborated with other professionals when necessary. | Program included a CGA that addressed the somatic, psychological, functional and social domains of participants’ lives. | Older people were involved in prioritizing care needs and developing their care plans. | |
The Netherlands | Potentially frail people aged ≥60 years who were enrolled in participating general practices. | Improve daily functioning of older people receiving primary care. | Program was delivered by an RN and GP. The RN collaborated with other professionals when necessary. | Program addressed biopsychosocial care needs. | During home visits, the RN focused on participants’ perceived care needs and preferences. | |
Sweden | People aged ≥80 years from an urban community who were cognitively unimpaired and not dependent on help with ADLs. | Delay the progression of frailty in older adults, preserve their health and quality of life, and minimize their need for health care. | Nurse, PT, OT and social worker collaborated to perform preventive home visits or facilitate group meetings for older people. | Preventive home visits and group meetings focused on the physical, psychological, social and environmental domains of participants’ lives. | Participants’ experiences formed the basis of the group meetings; they were the experts, whereas the professionals functioned as enablers. | |
Sweden | Older people ≥65 years living in one municipality containing both urban and rural areas, and who were cognitively unimpaired and had at least two ADL dependencies. | Decrease participants’ healthcare use and improve their life satisfaction and other outcomes. | RN delivered case management in collaboration with PT, municipal health and social care services, GPs and the university hospital. | Comprehensive assessment addressed multiple key domains such as function, health, social support, and services. | Older people were consulted regarding the goals and needs that are important to them, and the care activities implemented for them. | |
Switzerland | SpitexPlus [72] | People aged ≥80 years from an urban community who were cognitively unimpaired. | Promote self-care ability and skills for a home-based population aged 80 years and older. | The program was delivered by advance practice nurses who were trained by geriatric specialists. | Program identified health problems as well as social problems. | Program targeted the problems older people chose to focus on. |