Figure 1
Flow chart of literature screening.
Figure 2
Distribution of study design types.
Figure 3
Regional map of the study distribution.
Table 1
Characteristics of included studies.
| MODEL NAME | COUNTRY | PRACTICE SETTING | TARGET GROUP | MULTIDISCIPLINARY TEAM MEMBERS | ICT | PRACTICE PATH | SERVICE CONTENT | MAIN FINDINGS |
|---|---|---|---|---|---|---|---|---|
| PRISMA (a Coordination-Type Integrated Service Delivery System) [25, 26, 27] | Canada | Home | Frail elderly | Medical specialist, physiotherapist, occupational therapist, speech therapist, primary care physician, case managers (nurses, social workers or other health professionals, etc.) | Telephone, case-mix classification system, geriatric information system | Coordination of decision makers and managers at regional and local levels; Single entry point; Single assessment tool combined with a mixed case management system; Case management; Development and regular review of individualized service plans; Computerized clinical charting. | Home delivered meals, day center institutionalization, elderly care, professional care and rehabilitation services, therapy, home care, etc. | Preventing functional decline. Meeting the needs of elderly. Satisfaction and empowerment rates improved; Reduced caregiver burden. Improved utilization of healthcare services. The number of emergency room and inpatient admissions was lower than expected. |
| Bois-Francs Integrated Service Delivery (ISD) Network [28] | Canada | Community health center | Frail elderly | Health care professional, primary care physician, case manager | Geriatric Information System | Interdepartmental coordination at strategic, tactical and clinical levels; Single entry point; Single patient assessment tool; Case management; Development of personalized service plans; Computerized clinical charting. | Specialist medical services, home care, day care, rehabilitation, elderly care, primary care services, etc. | Reduced hospitalization rates and willingness to stay. Reduced caregiver burden. Delays the decline in function and deterioration of frail older adults in the short term. A smaller proportion of emergency visits resume within 10 days of the first visit. No significant difference in service utilization, emergency care, hospital admissions or medication use. |
| Transitional Care of Older Adults Hospitalized with Heart Failure [40] | United States | Hospital and home | Mental Failure Elderly | 3 Advanced practice nurses (APN), doctor | Telephone, tape and recorder audio material | 1.Hospitalization: comprehensive patient assessment, identification of patient and caregiver health goals, development and implementation of individualized care plans (guided by guidelines), provision of educational and behavioral strategies, arrangement of needed home care services, coordination with discharge planners for ordering of essential medical supplies. 2. After discharge home: targeted assessment to identify changes in the patient’s health status, implementation of symptom prevention or impact reduction strategies. | Specialist medical services, telephone follow-up, health education, home care, etc. | Extended the time between discharge and readmission or death. Decreased the total number of readmissions. Reduced medical costs. |
| Geriatric Resources for Assessment and Care of Elders (GRACE) [41, 42, 58] | United States | Hospital and primary care center | Low-income older adults | GRACE Support Team (1 Advanced practice nurse and 1 Social worker), Primary care practitioner, Geriatrician, Pharmacist, Physiotherapist, Mental health practitioner and Community services liaison | Electronic medical record, Regenstrief medical record system, telephone | In-home comprehensive geriatric assessment; Development of individualized care plans; Activation of GRACE protocols and team recommendations (based on practice guidelines); Review, revision and prioritization of care plans; Implementation of care plans; Weekly GRACE interdisciplinary team meetings; Care management and coordination of care; Telephone or face-to-face follow-up; Proactive follow-up of plans and provision of required health education materials. | 12 GRACE intervention programs (advance care planning, health maintenance, medication management, walking difficulties/falls, chronic pain, urinary incontinence, depression, malnutrition/weight loss, visual impairment, hearing loss, dementia and caregiver burden) | Reduced costs for high-risk patients. Improved quality of care for high-risk populations. Reduced acute care utilization. Better acceptance by patients and their primary care physicians and feasibility of the program. |
| Guided care [21, 29, 50, 51, 52, 53, 54, 55, 56] | United States | General practitioner (GP) clinic | Older adults at high risk of chronic disease | Guided Care Nurse (GCN), Primary Care Doctor | Telephone, electronic health record | In-home assessment of patients and primary caregivers; Determine the priority of optimizing health and quality of life; Development of evidence-based care plans; Promotion of patient self-management; Monthly telephone monitoring of patient conditions and actions; Coaching of patients in practicing health behaviors; Coordination of care; Education and support of caregivers; Referrals to accessible community resources. | Specialist medical services, evidence-based care, active monitoring, transitional care, self-management guidance, caregiver support, community services, etc. | Improved primary care experience and problem-solving skills for older adults at high risk of chronic disease. Increased satisfaction with care from primary care providers. Reduced use of hospital care, professional care, rehabilitation facilities, home health care and acute care. Has some service economy. |
| Multidisciplinary integrated care model [57] | Netherlands | Residential care facility | Older adults with physical or cognitive disabilities | Nurse assistant, family doctor, consultant (geriatrician or psychologist) | Electronic Integrated Geriatric Assessment Tool | Multidimensional geriatric assessment every three months; Discussion of assessment results and care priorities with family doctor, older adults and their families; Development of individualized care plans; Multidisciplinary team meeting; Geriatric or psychological specialist consultation (frail older adults with complex medical problems); Adjustment of care plans every three months based on risk assessment reports for older adults. | Support for activities of daily living, specialist care (medication guidance, wound care), home help, medication supervision, psychological counselling, etc. | Improved the quality of residential institutional care for older adults. A reduction in the number of deaths. No significant impact on improving functional capacity, number of hospital admissions and health-related quality of life. |
| Primary Integrated Interdisciplinary Elder Care at Home (PIECH) [80] | Canada | Home | Frail elderly | Community nurse, primary care physician, physiotherapist, doctor, nurse | Telephone, email, fax, electronic health record | 1.Primary care: comprehensive geriatric assessment, discussion and documentation of health care instructions, division of labor among team members in the provision of services. 2.Hospital care: hospital treatment, sharing of personal health records, clinical case management, provision of supportive care and assistance with discharge planning. | Case management, primary health care, specialist medical services (cryotherapy, joint injections, physiotherapy, bowel and bladder care, wound care), telephone consultations, home support, etc. | Reduced acute hospital admissions and facilitated family deaths. |
| Coordinated-Transitional Care (C-TraC) program [71, 72, 81] | United States | Hospital and home | Older veterans (with CHF and COPD) | C-TraC Nurse, Case Manager (Nurse) | Telephone, electronic medical record | Identification of eligible participants based on multidisciplinary discharge visits; Inpatient visits (to discuss medication management, post-discharge medical follow-up plan, red flags, contact information, etc.); Post-discharge telephone follow-up (to perform medication reconciliation, risk signal assessment, ensure appropriate follow-up, provide education, etc.) | Case management, palliative care, outpatient care, geriatrics and telemedicine, disease deterioration and coping education, medication management, etc. | Good fidelity of C-TraC program implementation. Reduced 30-day readmission rates for veterans. Saved an average of $1,842.52 per person in medical costs with lower operating costs and resources. |
| CareWell in Hospital program [82] | Netherlands | Hospital | Frail elderly surgical patients | CareWell team (1 geriatric care specialist and 1 geriatrician), nurse, doctor, volunteer team | Clinician and patient information system, nurse information system | Initial frailty screening and clinical judgement of admitted patients; Critical assessment of patient medical information and medication use; Proxy medical records; Comprehensive geriatric assessment; Multidisciplinary meetings; Development of CareWell plan; Follow-up during admission; Update of CareWell plan at discharge. | Specialist medical services, medication, end-of-life care, volunteer support, etc. | Improved the elderly’s ability to perform activities of daily living between hospital discharge and follow-up. Reduced caregiver burden 3 months after discharge from hospital. |
| Walcheren Integrated Care Model (WICM) [30, 31, 32, 33, 34, 39] | Netherlands | GP clinic | Frail elderly | GP, community nurse, hospital geriatrician, nursing home doctor, physiotherapist, social worker or psychologist, case managers (single-needs older adults: geriatric nurse; multiple or complex-needs older adults: second-line geriatric care specialist) | Patient file sharing system, telephone | Screening for frailty in older adults; Single entry point (primary care); Evidence-based comprehensive needs assessment; Development of multidisciplinary personalized service plans; Case management; Multidisciplinary team consultation and meeting; Protocol-led care assignment; Formation of steering groups (responsible for planning and implementing interventions); Task specialization and delegation; Chained computerized systems. | Telephone consultation, home visit, medical service, nursing home service, home care, day care, complementary medicine (physiotherapy, occupational therapy, nutrition), psychological care, informal caregiver support, etc. | Reduces the subjective burden on informal caregivers and increased possibility of assisting in housework. Improved the attachment dimension of quality of life for older adults. No significant impact on older adults’ health status, service provider workload and satisfaction and informal caregiver satisfaction with caregiving. WICM was not cost effective, with a higher cost per quality-adjusted life year. |
| Embrace integrated care program [19, 43, 44, 64, 83, 84] | Netherlands | GP clinic | Older adults | GP, nursing home doctor, case managers (community nurse and social worker), volunteer | Clinical information system, electronic records system for the elderly | Complexity of care needs and frailty assessment for older adults (robust, frail, complex care need);Case managers develop care and support plans in consultation with participants (robust: self-management support and prevention plans; frail and complex care need: individual care and support plans); Setting health goals and taking action; Case managers monitor participant status and plan implementation; Holding regular Embrace community meeting; Regularly assess care and support plans, update and adjust as necessary. | Needs and vulnerability assessment, specialist medical service, disease surveillance, health education, etc. | Embrace counteracted the decline in physical, cognitive and social functioning associated with ageing. Improved quality of care. Higher overall mean costs and small, statistically insignificant differences in health-related outcomes. |
| Integrated Care and Discharge Support for elderly patients (ICDS) [92] | Hong Kong, China | Hospital and home | Older adults | Link nurse, geriatrician, case managers (2 social workers, 1 physiotherapist, 1 occupational therapist and half an advanced practice nurse on a rotating basis), doctor, pharmacist, etc. | Telephone | 1. Hospital: multidimensional assessment of elderly patients, risk stratification, development of discharge plans, linkage to community services based on assessment results. 2. Community: Case management (out-of-hospital follow-up, coordination of community service, ensuring patient compliance with plans) and Home Support Team (HST) services. | Specialist medical services, case management, HST services (community support, meal delivery, home cleaning, respite care and home assessments and adaptations), etc. | Accident and emergency department visits, acute admissions and bed days have been reduced. ICDS had the potential to save on healthcare costs. |
| SmartCare program [75] | Austria, Croatia, Germany, Denmark, Estonia, Greece, Israel, Spain, Finland, Italy, Netherlands, Portugal, Serbia, United Kingdom, Czech Republic, Sweden | Hospital and home | Older adults | Nurse, GP, medical specialist, social worker, caregiver, third sector organization and volunteer | Electronic record system, electronic message, mail, fax, telephone, etc. | 1. Integrated care pathways: integrated long-term home care support (two entry points: referral by health care provider, referral by social care provider), integrated post-discharge home support (single entry point: discharge from hospital impending). 2. Integrating Care Processes: assessment of care recipient’s needs for long-term/short-term home care, enrolment to SmartCare service, initial integrated care plan, coordination of integrated care delivery/revision of initial integrated care plan, personalized multi-provider service package, shared documentation of home care provided, monitoring/review/reassessment of care recipient’s needs, temporary admission to institution/disenrollment from SmartCare service | On-site/home provision of informal care, formal health care, social care, telecare, social care, etc. | Reduced the number and length of hospital stays for older adults. Increased the ability of older adults to self-manage their chronic conditions. Reduced hours of care for caregivers. Care costs were reduced, with a certain cost-effectiveness. |
| CareWell primary care program [85, 86, 87, 88] | Netherlands | GP clinic | Frail elderly | GP, practice nurse and/or community nurse, geriatric nurse, pharmacist, social worker, case managers (nurse or social worker) | Health and welfare information portal (ZWIP), Electronic health record | Multidisciplinary team meetings (1 every 4–8 weeks); Proactive care planning (individualized care plans based on EASY-Care TOS assessment of individual health-related goals and needs); Case management; Medication reviews; Multidisciplinary practice guidelines, advance care planning practice guidelines for 8 common geriatric syndromes. | Medical, nursing and social support service, case management, medication guidance, etc. | No net monetary benefit. No significant impact on improving active functioning, quality of life, mental health, institutionalization, hospitalization and mortality in older adults; No observed effect on improving caregiver quality of life, caregiving burden. |
| Integrated care for geriatric frailty and sarcopenia [45] | Taiwan, China | Community hospital | Frailty and sarcopenia elderly | Nurse, sport specialist | Telephone, multimedia health education materials | 1.Low level of care(LLC): Provide 2-hour educational sessions (frailty, muscle loss, coping strategies, nutrition and learning exercise program presentations); distribute multimedia health education materials; telephone follow-up visit. 2.High Level Care (HLC): 6 on-site problem-solving sessions and 48 exercise sessions on an LLC basis, with brief nutritional advice during exercise. | Health education, exercise, nutritional counseling, telephone follow-up, etc. | Improved frailty and muscle loss of community elderly. Higher levels of care improve to a greater extent for high risk and highly motivated older adults. |
| Integrated care at home [46] | Switzerland | Home | Frail and dependent elderly | Primary care physician, nurse, doctor, physiotherapist and occupational therapist, psychologist, nutritionist and social worker | Telephone | In-home assessment by the Community Geriatrics Unit (CGU); Recommendations from the primary care physician and care team based on the assessment; Multidisciplinary team meetings to discuss complex issues; Coordination of care (primary care physician or CGU providing a 24h medical call service). | Primary care and home visit nursing service, 24h medical call service, etc. | Reduced unnecessary hospital admissions, emergency visits. Improved care coordination and access to services for frail and dependent older adults. |
| Health TAPESTRY Integrated care approach [20, 47, 65, 66] | Canada | Primary care clinic | Older adults | Family doctor, resident, nurse, pharmacist, various allied health professional, combination of volunteers (1 person with volunteer experience and 1 university student) | Health TAPESTRY application (TAP-App), electronic medical record, personal health record, telephone | Volunteer home visit (to discuss the health and life goals and needs of older adults); TAP-App based assessment data collection, creation of TAP reports; Review of TAP reports by volunteer coordinators; Regular interdisciplinary meetings to review reports; Development and implementation of personalized care plans; Community engagement and linkages. | Clinic visits, telephone consultations, specialist medical service, community service, etc. | Not improving patient goal attainment and reported outcomes. Increased the number of primary care visits for older adults. Reduced the incidence of 1 or more hospital admissions. Facilitated a shift from reactive to proactive and preventive care for patients. Initiatives to improve sustainability: team member engagement and training, clinical leadership involvement, infrastructure for sustainability. |
| Transitional care model for hospitalized cognitively impaired older adults [93] | United States | Hospitals and home/care facilities | Cognitively impaired elderly | APN, clinician, primary care provider | Telephone | Face-to-face assessment of patient and family caregiver needs and goals within 24 hours of admission; Inpatient visit; Design and implementation of care plans; Visitation and telephone services within 24 hours of discharge; Coordination of care (APN accompanies visits to primary care provider); Interdisciplinary team case review. | Specialist medical service, primary care service, telephone consultation, out-of-hospital follow-up, case management, etc. | Reduced the amount of post-acute care and the total cost of care. |
| Integrated Care for Older Adults with Complex Health Needs (iCOACH) [23] | Canada | Hospitals and community health centers/long-term care facilities | Elderly (complex health needs) | Doctor, nurse practitioner, nurse, pharmacist, community health worker | ICT system, electronic medical record | Institutional collaboration (supported by standardized referral procedures, single point of contact or shared assessment tools; clear division of responsibilities; mutual trust between providers); Holistic assessment of health and social care needs of older adults; Health education; Coordination of health and social services. | Home care, specialist medical service, primary health care, clinical assessment, health education, etc. | ICT application: community resource and policy, health system, delivery system, self-management support, decision support and clinical information system. Barriers to ICT use: barriers to cross-organizational access to information, lack of interoperability between organizational and regional systems, more limited application of IT functionality by providers. |
| INTESA integrated care project [59] | Italy | Nursing home | Frail elderly | Medical specialist, GP, physiotherapist, practice nurse, social health assistant, educator | DoEatWell App, INTESA subsystem, sleep monitoring sensor, pressure monitoring service mobile App | Personalized health indicator monitoring; Smart device-based collection, uploading and synchronization of monitoring data; Data analysis to calculate behavioral and physiological markers; Feedback and personalized guidance to GPs and caregivers. | Personalized monitoring service, 1h group cognitive and motor rehabilitation, 24h nursing home care service, social education activities, medical support (psychological, nutritional and neurological counselling), etc. | Perceived practicality, usability, acceptance and satisfaction of frail older adults was good. Some participants had a fear of adopting the INTESA equipment and implementing the recommendations and low self-confidence in completing the activities due to their frail health condition. |
| ICARE4EU project [60, 61] | Italy | — | Multi-morbid elderly | —— | Electronic health record (76%), personal health record platform (67%), digital communication between care provider (52%) | Of the 101 projects in Europe that integrate care for people with multiple morbidities, 31 use at least one eHealth technology and focus on people over 65 years of age. | Tele-consultation, monitoring and care; self-management, healthcare management, health data analysis (decision support) | Benefits of eHealth technology: care management, care integration, quality of care, cost efficiency, quality of life. Barriers to the use of eHealth technology: Lack of skills among providers, Inadequate technical ICT support, Lack of skills among patient, Inadequate legislative framework, Compatibility between different eHealth tool, Inadequate ICT infrastructures, Inadequate funding, Uncertainty of cost-efficiency, Privacy/security issues, Resistance by care providers, Cultural resistance, Resistance by patients |
| Salford Integrated Care Program (SICP)/Salford Together [76, 89] | United Kingdom | Community health center | Older adults (long-term illness and social care needs) | GP, nurse, district nurse, social care worker, mental health practitioner, occupational therapist and administrator | Telephone, shared care record, electronic medical record | Integration of community assets; Mobilization of older residents for local service improvement; Formation of integrated contact center; Screening and risk stratification of older adults; Shared care protocol; Care plans based on patient risk and need; Care and support; Multidisciplinary case conference. | Specialist medical service, telemonitoring, telecare, health coaching, mental health, community service, etc. | SICP had economic cost-effectiveness. Improved quality of life for patients. Increased use of community assets and care plans and positive health coaching experiences. |
| Finding and Follow-up of Frail older persons (FFF) [22, 35] | Netherlands | Home | Frail elderly | GP, practice nurse, family nurse or geriatric nurse, geriatric nurse practitioner, physiotherapist, case manager | Electronic medical record, GP information system, chain information system | Patient selection; Active frailty screening (reporting needs and problems); Feedback; Organization of multidisciplinary consultation; Creation of individualized care plans (lifestyle intervention, self-management measure, multidisciplinary follow-up and assessment plans); Medication review; Multidisciplinary follow-up. | Specialist medical service, home care, day care service, medication review, case management, self-management support, remote monitoring, etc. | Improved quality of care for frail older adults. FFF program was not cost effective. GPs saw structured funding and human, accessible ICT systems as key to the sustainable spread of FFF. |
| Comprehensive patient-centered strategy for multimorbid patients [73] | Spain | Hospital | Multi-morbid elderly | Liaison nurse, case manager, advanced skills nurse and internal medicine doctor | Electronic health record, electronic prescription | Development of chronic disease care plans for multidisciplinary teams; Coordination of care between different specialists during hospitalization; Telemedicine and empowerment services; Telecare services (coordination of care, sending health plan information or medication reminders, specialist training to address clinical and emotional problems). | Specialist medical service, telemedicine, telecare, telehealth education, primary care service, etc. | Reduced risk of admission to hospital for patients. |
| RESPOND (patient-centered program) [48] | Australia | Hospital and Home | Older adults attending A&E (falls) | 3 physiotherapists, 2 occupational therapists, 1 nurse and 1 nutritionist | Telephone | In-home assessment of fall risk factors; Provision of four educational leaflet modules (strength, vision, sleep, bone) and evidence-based information on risk factor management; Encouragement of participants to select relevant modules; Development of individualized goals and action plans for each module; Identification and resolution of issues that prevent participants from implementing the program; Telephone support; Communication and coordination of community services. | Emergency service, fall prevention exercise, risk factor assessment, health education, community service, etc. | Improved prognosis for emergency patients. Reduced falls and fractures in patients, but no reduction in fall injuries in older adults. |
| ProACT Integrated Care Platform [67, 91] | Belgium, Ireland | Home | Multi-morbid elderly | Informal care worker, formal/social care worker, community doctor, pharmacist and hospital doctor | Support CareApps, wearables, home-based sensor | Integration and coordination of care; Customization of the structure and functionality of CareApps based on the needs of older adults; Customization of data reports on the health and wellbeing of older adults using a color-coded traffic light system; Alerts and message pushing of abnormal values; Development of personalized health goals and self-management plans. | Telemonitoring, self-management education, clinical triage services, etc. | Older adults and stakeholders had a positive attitude towards the ProACT platform, with high perceived usability and benefits. Participation barriers: technical barriers (complex process of using devices and apps, lack of trust in the readings of smart monitoring devices), complexity of participants’ conditions. |
| CareWell integrated care model [36, 37, 77, 78] | Spain, Croatia, Poland, Italy, United Kingdom | Hospital and home/health center | Multi-morbid complex elderly | GP, social worker, medical specialist, care manager, primary care nurse (PC) | Electronic health record, electronic health call center, personal health folder | Screening of frail elderly patients; Comprehensive baseline assessment; Multidisciplinary case conference; Development of individualized care plans; Integrated care during hospitalization and coordinated discharge; Programmed follow-up; Patient empowerment and home care (KronikOn). | Telemonitoring, telemedicine consultation, medication prescription, transition support (coordination of referrals), patient follow-up, health education, etc. | Improved information, coordination and participation, patient empowerment and family support in the care process. Reduced the number of emergency room visits Reduced length of stay in hospital. Reduced patients’ body mass index, blood oxygen saturation and blood glucose Changed the use of health resources and strengthened the key role of primary care. Positive or negative socio-economic returns depending on the region. |
| BeyondSilos (Telehealth-Enhanced Integrated Care Model) [38] | Spain | Home | Elderly with chronic comorbidities | Doctor, nurse, social worker, family worker, volunteer and third-party group, case manager | Home care platform, telephone | 1.Care pathway: Integrated short-term family support following an acute episode; Integrated long-term family support. 2.Care processes: Ongoing assessment of older adults’ needs; Development and sharing of care plans; Single entry point(case manager); Regular visits or telephone contact with older adults; Ongoing follow-up of older adults’ health against care plans; Automatic alerts when health conditions deteriorate and accidents occur; Sharing of clinical information. | Specialist medical services (wound care, medication assistance, etc.), telemonitoring, telecare, home support (dietary and bathing support), volunteer accompaniment, etc. | Outstanding cost effectiveness. No significant effect on improving activities of daily living, depression. |
| Transitional care intervention for hypertension control [24] | China | Hospital and community health center | Geriatric diabetics | Medical specialist, GP, hospital discharge nurse, community nurse | Telephone | 1.Health care systems: two-way referrals. 2.Service providers: personalized discharge education, development of individualized medication regimens, post-discharge support. 3.Individual level: hospital (setting goals; implementing plans;), home (acting to achieve self-care goals; monitoring and recording changes in health status in the “Patient Edition of the intervention diary”; regular visits to community health centers or telephone support). | Specialist medical service, self-management education, personalized medication, telephone support, primary care visit, etc. | Improved control of hypertension in older diabetic patients. Reduced readmission rates. |
| Integrated Care for Older adults, (ICOPE) [79] | China, Andorra, France, India | Community and primary care institution | Older adults (reduced intrinsic capacity) | Geriatrician, GP/primary care physician, resident, nurse, occupational therapist, physiotherapist, psychologist, pharmacist, health assistant, volunteer | ICOPE Handbook APP | Screening for areas of reduced intrinsic capacity; Person-centered assessment in primary care; Developing individualized care plans; Ensuring referral pathways and monitoring care plans (link to specialist geriatric care); Coordinating community involvement and supporting caregivers. | Specialist medical service, telemonitoring, multi-component intervention, primary care management, self-care and management, social care and support | Good identification and enthusiasm for ICOPE among older participants. ICOPE has encouraged coordination and collaboration between health and care workers. Facilitators: active participation of older adults, training of providers, digital integration of health information. Hindrances: human resources, lack of infrastructure and systems integration, financial barriers. |
| INSPIRE ICOPE-CARE program [62, 63] | France | Hospital | Older adults | GP, nurse, physiotherapist, pharmacist, nutritionist, neuropsychologist and social worker | ICOPE MONITOR APP, BOTFRAIL internet conversation robot | Intrinsic capacity screening every 4–6 months; Person-centered assessment in primary care; Identification of care goals and development of individualized care plans; Ensuring referral pathways and monitoring of care plans with links to specialist geriatric care; Coordination of community involvement and support for caregivers. | Telemonitoring, telehealth consultation, telehealth education (nutrition, exercise), specialist medical service, etc. | The program had some feasibility. 70.4% of participants completed the 6-month follow-up screening 94.3% of older adults had a decline in at least one area of intrinsic ability. |
| Systems for Person-Centered Elder Care (SPEC) [17, 90] | Korea | Nursing home | Frail elderly | Nursing home manager, nurse practitioner, social worker, physiotherapist, occupational therapist and nutritionist, SPEC coordinator (1 nurse, 1 social worker) | SPEC Information System, KaKao Talk APP | Integrated geriatric assessment (needs and risk analysis); Individualized care plans based on needs; Interdisciplinary case conferences; Coordination of care with family members, external health professionals and agencies; ICT support (sharing health assessment data, monitoring progress of interventions, providing information support). | Daily nursing home care, specialist medical service, etc. | SPEC plan had good fidelity. Improved the overall quality of care in nursing homes. Prevented deterioration of late ADL loss, cognitive and communication decline, new or persistent delirium and behavioral problems from occurring. |
| Personalized Connected Care (CONNECARE) project [49] | Spain | Home | Older adults with complex chronic conditions | Family doctor, hospital surgical team and social worker, case manager | Smart Adaptive Case Management System, Mobile Self-management System, Wearable monitoring devices | Initial assessment of patient health status; Generation of health status reports based on the self-management system; Customized virtual coaching with automatic feedback; Automatic tracking of patient activity; Shared patient profiles; Coordination of professional service providers; Case managers overseeing the entire care process. | Virtual coaching, nursing and social services, case management, etc. | Improved quality of life for patients. Reduced the number of unplanned visits and hospital admissions. Cost-effective savings of approximately €109.88 – €126.99 per patient. |
| Coordinated Care At Risk/Remote Elderly program (CCARRE) [68] | United States | Home | Cognitively impaired elderly | Bilingual/bicultural social worker, neurologist, primary care physician | Telephone, secure video platform | Telemedicine visits; comprehensive geriatric assessment; CCARRE medical review; Discussion of advance care planning, contingency planning and respite needs; Development of a comprehensive care plan for the patient’s cognitive status and presenting problems; Discussion of the CCARRE plan with the patient and caregivers; Shared plan reporting and coordination of care. | Teleassessment, telemedicine visit, health education, medication guidance, specialist medical service, respite service, etc. | Improved patient care. Reduced caregiver burden. Optimized access to community resources. |
| Person-Centered Care Through Videoconferencing [18] | Norway | Hospital and primary care institution | Older adults (with complex and long-term needs) | Doctor and medical secretary, nurse coordinator, geriatric nurse, physiotherapist and occupational therapist, pharmacist, case manager | Video conferencing platform, electronic health record system | Comprehensive geriatric assessment; Agreeing care goals with the patient; Developing an evidence-based care plan; Driving and implementing the care plan based on what is “important to the person”; Ongoing assessment and delivery of the care plan; Daily multidisciplinary team meetings. | Health care service, specialist medical service, medication guidance, etc. | Videoconferencing-based service delivery provided the opportunity for effective access to health care professionals. Reduced travel time for patients to access medical care. Improved information exchange between healthcare levels. |
| Integrated geriatric outpatient services (IGOS) [74] | Taiwan, China | Hospital | Multi-morbid elderly | Geriatrician, nurse, case manager | Telephone | Comprehensive geriatric assessment; interdisciplinary team care; person-centered care planning; single entry point (elderly patients with multiple complex care needs were primarily cared for by geriatricians) | Outpatient services, specialist medical services, case management, etc. | Improved quality of life for older adults with multiple morbidities. No significant impact on the improvement of quality of life for older adults with poorer nutritional status, depression and frailty. |
| RubiN (Continuous Care in Regional Networks) [69, 70] | Germany | Primary care institution | Older adults | GP, specialist, nurse, physiotherapist, occupational therapist, healthcare assistant, 4 case managers | Geriatric Care Network | Risk assessment; Classification of patients as mild, moderate or severe cases according to their care requirements; Development of individualized and optimal treatment and/or care plans; Coordination and organization of medical care; Organization of case discussions and “round tables” to assess patient care. | Nurse support, social services, nutritional advice, exercise guidance, health management, risk identification and management, case management, etc. | RubiN created networks and support for family caregivers Reduced caregiver burden. Older adults experienced the security of caregiving. |