Redesigning Community Dwelling Geriatric Integrated Care Program for Better Care Co-Ordination and Health Outcomes

Abstract Background Existing health services and care models need to adapt to the increasing ageing population, multimorbidity, and frailty. Thus, diverse healthcare providers and caregivers are demanded to continue living at home. An Integrated Care Program, involving a multidisciplinary team with...

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Bibliographic Details
Published in:Age and ageing 2024-09, Vol.53 (Supplement_4)
Main Authors: Marion, Ikhwan, Cribbin, Derek
Format: Article
Language:English
Subjects:
Advanced nurse practitioners
Caregivers
Clinical outcomes
Community living
Community service
Evaluation
Frail
Health services
Health status
Implementation
Independent living
Integrated care
Integrated delivery systems
Interdisciplinary aspects
Literature reviews
Multidisciplinary teams
Nurse led care
Older people
Ordination
Patient-centered care
SWOT analysis
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Summary:Abstract Background Existing health services and care models need to adapt to the increasing ageing population, multimorbidity, and frailty. Thus, diverse healthcare providers and caregivers are demanded to continue living at home. An Integrated Care Program, involving a multidisciplinary team with a patient-centred focus, is being promoted as an alternative model of care. However, uncoordinated existing services put them at risk of fragmented care, leading to adverse outcomes. This study aimed to fill gaps in previous ICP research by introducing a change roadmap into the implementation phase of the program. In addition, the study proposed evaluating the effectiveness and implementation of the pilot project together with the process evaluation. Methods The study conducted a systematised literature review to examine the outcomes and different structures of the ICP. Implementation Science was utilised to define, design, and deliver the model of change. Results A systematised literature review showed that most ICPs were led by an Advanced Nurse Practitioner with positive outcomes. SWOT analysis, stakeholders’ involvement, existing community service providers, and a population survey provide an in-depth perspective of the target population and set up contextually adapted implementation strategies. An ANP-led MDT was proposed to co-ordinate the ICP. A process evaluation to assess the care model together with health outcomes was outlined. Conclusion The study showed that ANP-led MDT, person-centred, co-ordinated care provides the best ICP implementation strategy. The study will further understand the ICP implementation process among frail older people in the community.
ISSN:0002-0729
1468-2834
DOI:10.1093/ageing/afae178.041