Jiang Biyan, Li Baiyu, He Shijia, Chen Lingyan, Yang Shulan, Liu Jiabin, Lou Weimin, Hu Yiyu, Jin Xiaoqing, Liu Caixia
Department of Nursing, Zhejiang Hospital, No. 1229, Gudun Road, Xihu District, Hangzhou, Zhejiang, China.
Department of Geriatric Medicine, Zhejiang Hospital, No. 1229, Gudun Road, Xihu District, Hangzhou, Zhejiang, China.
BMC Geriatr. 2025 May 10;25(1):324. doi: 10.1186/s12877-025-05956-z.
Integrated Care for Older People (ICOPE), developed by the World Health Organization (WHO) with a global perspective, faces varying degrees of barriers to implementation, particularly in middle-and low-income countries. Therefore, as with other new public service interventions, we draw on established integrated care interventions to design a Theory of Change (ToC) model for ICOPE, and to propose methods and pathways for adapting community-based integrated care models for older people (OP) to specific contexts, thereby updating and enhancing the implementation of ICOPE.
An initial ToC for the ICOPE was drafted based on the WHO guidelines and published literature, and synthesizing the results of semi-structured interviews, group discussions. A total of 36 healthcare stakeholder experts in geriatric nursing, geriatric care and chronic disease management, rehabilitation and quality of life, and psychiatric-mental health were recruited to participate in a 5-stage ToC group workshop conducted consecutively. Each workshop has 2-3 facilitators, and lasts from 60 to 120 min. In multiple workshops, the experts discussed the causal pathway, the interventions needed to activate it, the underlying principles and assumptions, evaluated and refined them, and finally reached consensus.
The ToC design has improved the ICOPE program, identifying the resources, long-term outcomes, and impacts required for the implementation of ICOPE in a specific setting, and clarifying the specific components of the integrated care interventions, such as materials, procedures, and intervention providers. The localized, OP-centred model of integrated home care developed in our study may contribute to healthy ageing through four potential long-term outcomes: (1) reduction of unnecessary hospitalizations and increased utilization of referral services, (2) enhancement of self-care capacity to prevent, reverse, or delay the decline of intrinsic capacity in OP, (3) improvement of the quality of life of OP living at home, and (4) reduction of caregiving burdens and improvement in the level of caregiving.
The ToC is effective in identifying key characteristics of resources, interventions, impact, and outcomes of integrated care for OP. Our ICOPE program has been strengthened by ToC, which forms an integrated care model for assessment, planning, implementation, and evaluation, adapted to a specific setting, and provides guidance for other areas in similar settings.
世界卫生组织（WHO）制定的老年人综合照护（ICOPE）具有全球视野，但在实施过程中面临不同程度的障碍，尤其是在中低收入国家。因此，与其他新的公共服务干预措施一样，我们借鉴已有的综合照护干预措施，为ICOPE设计一个变革理论（ToC）模型，并提出使基于社区的老年人（OP）综合照护模式适应特定环境的方法和途径，从而更新和加强ICOPE的实施。
根据WHO指南和已发表的文献，综合半结构化访谈、小组讨论的结果，起草了ICOPE的初始ToC。共招募了36名老年护理、老年照护与慢性病管理、康复与生活质量以及精神心理健康方面的医疗利益相关者专家，连续参加一个5阶段的ToC小组研讨会。每个研讨会有2至3名主持人，持续60至120分钟。在多个研讨会上，专家们讨论了因果路径、激活该路径所需的干预措施、潜在原则和假设，对其进行评估和完善，最终达成共识。
ToC设计改进了ICOPE项目，确定了在特定环境中实施ICOPE所需的资源、长期结果和影响，并明确了综合照护干预措施的具体组成部分，如材料、程序和干预提供者。我们研究中开发的以OP为中心的本地化居家综合照护模式可能通过四个潜在的长期结果促进健康老龄化：（1）减少不必要的住院次数并增加转诊服务的利用率；（2）增强自我照护能力，以预防、逆转或延缓OP内在能力的下降；（3）改善居家OP的生活质量；（4）减轻照护负担并提高照护水平。
ToC有效地识别了OP综合照护的资源、干预措施、影响和结果的关键特征。我们的ICOPE项目通过ToC得到了加强，ToC形成了一个适应特定环境的评估、规划、实施和评价的综合照护模式，并为类似环境中的其他领域提供了指导。
