‘It would nearly put the life back into you’ Older adults’ experiences of a Community Specialist Team for Older People (CSTOP) service model in Ireland: A Qualitative Descriptive Study

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In Ireland, there has been a substantial recent investment in the 30 Community Specialist Team for Older People (CST OP) service model. This 31 approach provides timely integrated assessment and intervention for older adults in 32 the community by a specialist multidisciplinary team. To inform the ongoing 33 development and refinement of the CST OP service model, and ensure it is 34 responsive to the needs and preferences of older adults, it is important to understand 35 how older adults experience this new model of care. This qualitative descriptive 36 study aims to resolve a research gap by exploring older adults’ experiences of the 37 CST OP service model. 38

A qualitative descriptive study design was employed to explore older 39 adults’ experiences of the CST OP service model. Purposive non-probability 40 sampling was used to recruit 13 older adults who had completed intervention with a 41 CST OP intervention. All interviews were completed in participants own homes, 42 audio recorded and transcribed verbatim. A reflexive approach to thematic analysis 43 guided data analysis. 44 Findings: Three themes were identified; older adults were uncertain about what to 45 expect from the CST OP service and encountered accessibility barriers (theme1); 46 the CST OP team provided coordinated, comprehensive care and built strong 47 relationships with older adults (theme 2); CST OP intervention enabled older adults 48 to better manage everyday activities and long-term conditions, thereby improving 49 their wellbeing (theme 3). 50 Discussion/ conclusion: Our findings highlight the importance of CGA in 51 community-based care for older adults. Further research is needed to address 52 access barriers and evaluate older adults' experiences with case management and 53 care coordination in the CST OP service model. 54

Older Adult, Community Specialist Team for Older Adults, Integrated 55 Care, Experiences, Qualitative. 56 57 All rights reserved. No reuse allowed without permission. preprint (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for thisthis version posted December 16, 2024. ; https://doi.org/10.1101/2024.12.13.24318927doi: medRxiv preprint 3 58

59 Ireland currently has the fastest aging population in Western Europe (Sheehan and 60 O’Sullivan, 2020). By 2051, it is projected that 26% of the population will be over the 61 age of 65 (Sheehan and O’Sullivan, 2020). The World Health Organization (WHO) 62 has identified that a fundamental shift in healthcare delivery is needed in response to 63 population ageing, away from a fragmented care system, towards person-centred 64 integrated care (WHO, 2015a). 65 Integrated care for older people refers to services that span the entire care 66 continuum, integrating different levels and sites of care, while being tailored to meet 67 individual’s needs (WHO, 2015b). Emerging research on integrated care models has 68 demonstrated benefits for access to care (Baxter et al., 2018), quality of life, patient 69 satisfaction, perceived quality of care (Baxter et al., 2018; Uittenbroek et al., 2016; 70 Hayes et al., in press; Yan Wang et al., 2024) and weak beneficial effects on health 71 outcomes for older adults (Kirvalidze et al., 2024). Additionally, these co-ordinated 72 community-based approaches may reduce hospital admission rates and lengths of 73 hospital stay for older adults (Liljas et al., 2019). 74 In Ireland, the Integrated Care Programme for Older Persons (ICOPOP) aims to 75 develop and implement integrated services and pathways for older people with the 76 development of community based, planned and coordinated care (ICPOP, 2017). A 77 key component of this program is the Community Specialist Team for Older People 78 (CST OP) service model of care. CST OP teams typically comprise a range of 79 community-based healthcare professionals, including nurses, physiotherapists, 80 occupational therapists, case manager, speech and language therapist’s, dietitians 81 and consultant geriatricians (Health Service Executive, 2024a). These teams enable 82 timely access to Comprehensive Geriatric Assessment (CGA) where the different 83 healthcare professionals work together to assess and to respond to an older 84 person’s medical, functional and social needs (Health Service Executive, 2024a). In 85 this model of care primary and secondary care services work together to avoid 86 unnecessary hospital admissions for older adults (Fitzgearld et al., 2023). 87 88 All rights reserved. No reuse allowed without permission. preprint (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for thisthis version posted December 16, 2024. ; https://doi.org/10.1101/2024.12.13.24318927doi: medRxiv preprint 4 The British Geriatrics Society has advocated for the involvement of older adults in 89 the co-design, delivery, and ongoing monitoring of Integrated Care services (British 90 Geriatrics Society, 2024), a view echoed in Irish integrated care policies (ICPOP, 91 2017) and in academic literature (Sadler et al., 2019). Research suggests that there 92 may be substantive differences between healthcare providers perspectives of 93 integrated care and older adults’ perspectives (Sheaff et al., 2017). Through their 94 qualitative systematic review, Karascony and colleagues identified a lack of older 95 adult voices, particularly from the oldest-old population, in the current evidence base 96 on the clinical and social outcomes of integrated care (Karascony et al., 2022). This 97 suggests that further research is needed to more comprehensively capture the 98 experiences and needs of this demographic, who may have distinct requirements 99 and preferences compared to younger older adults. 100 Methodology: 101 Study Aim: 102 The aim of this research is to explore older adults’ experiences of the CST OP 103 service model within the Irish Healthcare context. 104 Design: 105 A qualitive exploratory descriptive approach was adopted (Daly et al., 2007) using 106 semi-structured interview methodology and reflexive thematic analysis (Bruan and 107 Clarke, 2019) to explore older adults’ experiences of CST OP model of care in the 108 Mid-West region of Ireland. Given that the CST OP service model was newly formed, 109 this research design aligned with our aim of presenting comprehensive detailed 110 summary of participants experiences and without use of a theoretical framework 111 (Kim et al., 2017). This study was conducted in parallel to a cohort study exploring 112 older adults’ health outcomes following intervention by CST OP (Hayes et al., in 113 press). The conduct and reporting of this study were in accordance with the 114 Consolidated Criteria for Reporting Qualitative Research (COREQ) checklist 115 (supplementary file 1) for focus groups and interviews to ensure rigor, 116 comprehensiveness, and credibility of the research study (Tong et al., 2007). 117 Context / setting: 118 All rights reserved. No reuse allowed without permission. preprint (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for thisthis version posted December 16, 2024. ; https://doi.org/10.1101/2024.12.13.24318927doi: medRxiv preprint 5 The setting of participant recruitment was from three CST OP services within 119 Ambulatory Care Specialist Hub (ACSH) sites (Ennis, Limerick and Thurles) in the 120 Mid-West region of Ireland which has a population of just over 400,000 (Health 121 Service Executive, 2024b). The profile of the population in this region is older and 122 more deprived than the national comparator (Health Service Executive,2024b). 123 Additionally, between 2016 and 2022, the 75–79-year age group increased by 124 almost 40%, and the 85 years and older age group increased by 25% in this region 125 (Health Service Executive,2024b). Older adults were recruited after their intervention 126 with CST OP team thus, inclusion and exclusion criteria for prospective participants 127 to the study was based on referral criteria to the CST OP team as outlined in the 128 table 1.1 129 130 131 132 133 134 135 136 137 138 139 140 141 142 143 144 All rights reserved. No reuse allowed without permission. preprint (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for thisthis version posted December 16, 2024. ; https://doi.org/10.1101/2024.12.13.24318927doi: medRxiv preprint 6 Inclusion Criteria for CST OP intervention Exclusion Criteria for CST OP intervention Participants must meet the following criteria to be accepted into the CST OP intervention: Referral Sources: Referred to the CST OP Hub via an urgent referral from a General Practitioner or from the Emergency Department (ED) at University Hospital Limerick. Referral Sources: All of criteria 1-5 must be met: 1. Aged 75 years or older. 2. Evidence of frailty, scoring between 4 and 6 on the Rockwood Clinical Frailty Scale pre-frail to mildly frail or moderately frail (Rockwood et al., 2005) 3. Residing within Community Healthcare Organisation 7 (Clare, North Tipperary and Limerick) and the catchment area of the relevant ICP OP team. 4. Seen in-person by the referrer to CST OP Team. 1. Presentation with an acute neurological or cardiovascular event. 2. An alternative care pathway or service e.g. primary care or geriatric medicine clinic, is more appropriate. 3. Presentation with injuries, unless the injury has already been appropriately managed. 4. Experiencing an acute medical illness requiring treatment in an acute hospital setting. 5. Care is being provided by other health care professionals at the time of referral and it is apparent that they are working to meet goals aligned with the current service. 6. Investigation or treatment not available in the relevant CST OP hub are required (unless these investigations are already being arranged elsewhere). 7. Individual has received MDT input in the last three months 8. Individual has confirmed or suspected Covid-19 infection or other exclusions at the discretion of the integrated care team based on clinical expertise and available resource. All rights reserved. No reuse allowed without permission. preprint (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for thisthis version posted December 16, 2024. ; https://doi.org/10.1101/2024.12.13.24318927doi: medRxiv preprint 7 145 5. They have not had Multidisciplinary Team (MDT)input within the last three months (excluding ‘Optimising early assessment and intervention’ by Health and Social Care Professionals in the Emergency Department at University Hospital Limerick). And any one of criteria 6-9 must be met 6. Fall within the last month unrelated to acute cardiac or neurological cause and no previous falls assessment increased dependency or increased carer burden in the last month. 7. A deterioration in swallow in the last month including symptoms of recurrent chest infections, weight loss, coughing when eating/drinking, self-modifying diet secondary to difficulties. 8. Adverse drug reaction within the last month excluding allergic reaction. 9. Referred from General Practitioner or Emergency Department and Acute Medicine Unit following review by consultant in Emergency Medicine, Acute Medicine, Geriatric Medicine, General Medicine or Frailty at the Front Door team. All rights reserved. No reuse allowed without permission. preprint (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for thisthis version posted December 16, 2024. ; https://doi.org/10.1101/2024.12.13.24318927doi: medRxiv preprint 8 Table 1.1 Inclusion and exclusion criteria 146 All rights reserved. No reuse allowed without permission. preprint (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for thisthis version posted December 16, 2024. ; https://doi.org/10.1101/2024.12.13.24318927doi: medRxiv preprint 9 Sampling and recruitment 147 Purposive non-probability sampling was applied to select prospectively older adult 148 participants who had completed intervention with the CST OP. A research nurse 149 (CD) involved in the parallel cohort study acted as a gatekeeper by providing study 150 information (participant information leaflet, consent form) to potential participants 151 who met the inclusion criteria. Alongside inclusion criteria, the gatekeeper 152 considered variation of participants regarding gender, age, and social circumstances 153 (living alone /with others) as participant recruitment progressed. Participants were 154 equally recruited from the three CST OP sites (rural and urban settings). After 155 explaining the study aim and providing an opportunity to ask questions, if a 156 prospective participant expressed an interest in taking part, the research nurse (CD) 157 obtained consent to share their contact details with the male qualitative interviewer 158 (BC). The research nurse (CD) and interviewer (BC) had no direct care involvement 159 with prospective participants. The interviewer (BC) contacted them by phone and an 160 interview date/time was scheduled. 161 Positionality & reflexivity 162 Participant interviews, interview transcription, open coding of transcripts and data 163 analysis were conducted by the lead author (BC) under supervision of the wider 164 research team. The lead author is a registered occupational therapist with over 165 fourteen years clinical experience working with older adults and is a PhD candidate 166 who has completed postgraduate training in qualitative research. Interviewees knew 167 he was a PhD candidate and did not know he was an occupational therapist. 168 Members of the wider research team have clinical and qualitative research 169 experience with older adults in their respective roles: general practitioner (LG), 170 geriatrician (MOC, ES, AL), physiotherapist (RG, CH), dietitian (AG), speech and 171 language therapist (MM), nurse (CF, CD) and occupational therapist (KR, BC). 172 Data Collection: 173 All interviews were conducted in participants homes at various locations in the Mid- 174 West region and each interview was conducted by the same interviewer (BC). On 175 occasion, at the request of participants (n=4), family members were present during 176 the interviews. This was especially helpful for participants with sensory impairments, 177 as family members could clarify if older adults had heard the interview questions 178 All rights reserved. No reuse allowed without permission. preprint (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for thisthis version posted December 16, 2024. ; https://doi.org/10.1101/2024.12.13.24318927doi: medRxiv preprint 10 posed by the interviewer (BC). However, family members did not answer on 179 participants behalf and no data collected from participant family members was used 180 within this study. No repeat interviews were required. 181 At the outset of each interview, participants were given an opportunity to ask any 182 questions about participating in the research study. Those who agreed to participate 183 signed two copies of a consent form (one was kept by the researcher, and one 184 remained in the participants home). Field notes were taken after each interview and 185 recruitment ceased when data saturation was reached, the point at which there was 186 no further additional emergence of issues/ views with repetition of same data thus, 187 making further data collection redundant (Hennick et al., 2022). Saturation was 188 determined by the interviewer (BC) and another member of the research team (KR) 189 Individual semi-structured interviews were conducted with the interview topic guide 190 developed from findings from a recent study exploring older adult’s experiences 191 transitioning from the ED (Condon et al., 2024) and a literature review on the topic 192 area. Additionally, an older person and family caregiver Public and Patient 193 Involvement Panel, and research experts in the area were consulted. The topic guide 194 focused on three main concepts: overall experience at the CST OP, experience of 195 care delivery at the CST OP, experience of communication and the discharge 196 process at the CST OP (see supplementary file 2). A pilot of the semi structured 197 interview guide was completed by the lead researcher (BC) with an older adult who 198 provided feedback on length and focus of the topic guide questions, no amendments 199 were made following the pilot. The pilot interview was included in the study. The 200 semi structured interviews were audio-recorded, transcribed in full, and exported to 201 NVivo version 14 Pro Software (Lumivero,2024). Transcripts were not returned to 202 participants for comment and correction to ensure integrity of the data as all audio 203 recordings were clear and high quality for accurate transcription (Morse et al., 2015). 204 Data Analysis: 205 A reflexive approach to thematic analysis as described by Braun and Clarke guided 206 the analysis of the data (Bruan and Clarke, 2019). This reflexive approach aligns 207 with the qualitative descriptive design and is appropriate given the lead researchers 208 dual role as both a researcher and a clinician (Braun and Clarke, 2019). The 209 emphasis on researcher reflexivity in this approach supported identification of the 210 All rights reserved. No reuse allowed without permission. preprint (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for thisthis version posted December 16, 2024. ; https://doi.org/10.1101/2024.12.13.24318927doi: medRxiv preprint 11 researcher role at all stages of the study. An iterative approach to analysis was 211 applied to which data collection and analysis occurred concurrently to inform one 212 another (Morgan and Nica, 2020). Data was analysed inductively to generate 213 analytical codes using a ‘bottom up’ approach, rather than deductive, ‘top-down’ 214 application of a priori theories or frameworks. Themes were identified on a semantic 215 level (explicit or overt meanings), placing the focus explicitly on transcript content 216 (Braun and Clarke, 2019). 217 The six steps outlined by Braun and Clarke were conducted: familiarisation with data, 218 generating initial codes, searching for themes, defining, and naming themes and 219 producing the report were followed in the data analysis stage (Bruan and Clarke, 220 2019). In step one, the lead author (BC) read and re-read the transcripts in detail in a 221 process of in-depth data immersion and familiarisation. This was followed by the lead 222 author generating initial codes (forming a coding tee) using NVivo version 14 Pro 223 Software (Lumivero,2024). The lead author had attended workshops on thematic 224 analysis. Concurrently, the coder (BC) gained consensus on major topics and 225 subtopics with two members of the research team (KR, AG) who have established 226 qualitative expertise. This step was achieved through frequent research meetings 227 involving critical discussion and debriefing between three research members (BC, 228 KR, AG). 229 The third step of thematic analysis ‘searching for themes’ was commenced by three 230 members of the research team (BC, KR, AG) in identifying overlapping codes 231 leading to generated themes representing a pattern of data from the interviews 232 (Braun and Clarke, 2006). Step four involved reviewing potential themes by 233 members of the research team (BC, KR, AG). This involved judging whether there 234 was sufficient interview data to underpin each generated theme. In step 5 ‘naming 235 the themes’ clear names and definitions were applied to each generated theme. In 236 the final step a final report in the version of this manuscript was completed. The 237 findings of the study were not shared with participants as further research was 238 planned in this research area. 239 Ethical considerations: 240 Ethical approval was gained from the Health Service Executive (HSE) Mid-Western 241 Regional Hospital Ethics Committee at University Hospital Limerick in December 242 All rights reserved. No reuse allowed without permission. preprint (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for thisthis version posted December 16, 2024. ; https://doi.org/10.1101/2024.12.13.24318927doi: medRxiv preprint 12 2021 (Research Ethics Committee Reference:116/2021). Interviews only 243 commenced when informed consent from participants was received and to protect 244 their privacy and confidentiality, all participants names were de-identified with each 245 participant provided with a unique participant number. The gatekeeper (CD) and lead 246 researcher (BC) were the only members of the research team who could identify the 247 data. Any identifiable information (e.g. patients name, home address etc.) was 248 removed or adapted from participants quotes used to illustrate findings within this 249 study. 250 Participant Characteristics 251 Sixteen older adults were initially recruited, two participants did not return a consent 252 form and subsequently were not interviewed, and one participant withdrew from the 253 study after being interviewed. All thirteen interviews included in this study were 254 conducted between April 2023 and September 2023, with interviews lasting between 255 20 and 60 minutes. Data from interviews with thirteen older adults, female (n=10) 256 and male (n=3) are presented. Participants reported diverse socio-economic 257 backgrounds based on Pobal Haase and Pratschke Deprivation Indices (Haase and 258 Pratskhke, 2022): marginally above socio- economic (n=7), marginally below socio-259 economic (n=5) and disadvantaged socio-economic (n=1). Additionally, participants 260 were recruited/included from both rural (n=2) and urban settings (n=11). Participants 261 demographics is detailed in table 1.2 262 Participants ages ranged from 77 to 95 with a mean age of 85.38 years of age. The 263 presenting problem for participants attending CST OP included falls (n=7), dizziness 264 (n=1), increased frailty (n=1), Parkinson disease (n=1), and functional decline (n=2). 265 All included participants were seen by a medical team member of the CST OP team 266 (n=13) with only four participants not seen by the physiotherapist (n=11) and four not 267 seen by nursing staff (n=12).268 All rights reserved. No reuse allowed without permission. preprint (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for thisthis version posted December 16, 2024. ; https://doi.org/10.1101/2024.12.13.24318927doi: medRxiv preprint 13 Participant Number Gender Length of recording Age Ethnicity Residential Status Presenting problem Disciplines seen at CST OP 1 F 33.49 mins 75-80 White Irish Lives alone Falls MT, PT, Diet. 2 M 53.49 mins 85-90 White Irish Lives alone Falls MT, PT, OT 3 F 20.55 mins 80-84 White Irish Lives with family Reduced mobility MT 4 F 20.55 mins 80-84 White Irish Lives with family Falls MT 5 F 38.29 mins 75-80 White Irish Lives with other Parkinson disease. MT, PT, SLT, CNS 6 F 26.03 mins 90-95 White Irish Lives with other Dizziness MT, PT, CNS 7 M 30.55 mins 90-95 White Irish Lives with other Falls MT, ANP, PT, SLT 8 F 31.01 mins 90-95 White Irish Lives alone Falls MT, CNS, PT, 9 F 32.11 mins 80-84 White Irish Lives alone Falls MT, ANP, PT 10 F 31.11 mins 90-95 White Irish Lives alone Functional decline MT, ANP, CM, PT, SLT, OT All rights reserved. No reuse allowed without permission. preprint (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for thisthis version posted December 16, 2024. ; https://doi.org/10.1101/2024.12.13.24318927doi: medRxiv preprint 14 Table 1.2 Participant demographics MT=Medical Team, PT= Physiotherapy, OT= Occupational Therapy, Diet= Dietician, CM= Case Manager, SLT= Speech and language therapist, ANP= Advanced Nurse Practitioner, CNS=Clinical Nurse Specialist 11 F 13.18 mins 90-95 White Irish Lives with other Falls MT, CNS, CM, SLT 12 F 28.08mins 75-80 White Irish Lives with other Increased Frailty MT, CNS 13 F 58.36 mins 75-80 White Irish Lives with other Falls MT, CM, CNS, PT All rights reserved. No reuse allowed without permission. preprint (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for thisthis version posted December 16, 2024. ; https://doi.org/10.1101/2024.12.13.24318927doi: medRxiv preprint 15 Findings: 269 Three overarching themes were generated from the data which will be presented as 270 our findings. Older adults were uncertain about what to expect from the CST OP 271 service and encountered accessibility barriers (theme 1). The CST OP team 272 delivered positive, coordinated, and comprehensive care, and developed strong 273 therapeutic relationships with older adults (theme 2). CST OP intervention enables 274 older adults to better manage everyday activities and long-term conditions, 275 enhancing emotional well-being (theme 3). 276 Theme 1: Older adults were uncertain about what to expect from the CST OP 277 service and encountered accessibility barriers. 278 This theme relates to older adults’ expectations of CST OP prior to engaging with the 279 service. They welcomed being referred to the service however, many reported a lack 280 of prior knowledge about the service prior to attending, leaving them uncertain about 281 what to expect. Furthermore, some older adults described difficulties attending 282 appointments due to due to transportation dependencies. 283 Prior to attending the CST OP, symptoms and challenges reported by older adults 284 included falls, pain, infections, palpitations, reduced confidence, social isolation, and 285 grief. In certain situations, these symptoms impacted on their ability to manage at 286 home for example, one participant described how they were afraid to go up and 287 down the stairs at home. Additionally, another participant described how their 288 palpitations were disturbing their sleep. 289 ‘I was on crutches for a long time and my shoulders then were giving me a lot 290 of problems, so I had physical and mental problems. As a result, you know the 291 grief I went through and then to find I couldn't walk’ (Participant 9) 292 Prior to CST OP some participants required spousal, family or formal caregiver 293 assistance to complete daily activities. By attending CST OP, older adults hoped to 294 regain lost abilities, such as return to driving, increased walking, and stair climbing. 295 Older adults interviewed in this study reported that, both the General Practitioners 296 (GPs) and hospital doctor who referred them to the CST OP service had limited 297 knowledge about the service. Additionally, several participants reported that they 298 were unaware of who and why they were referred to CST OP. 299 All rights reserved. No reuse allowed without permission. preprint (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for thisthis version posted December 16, 2024. ; https://doi.org/10.1101/2024.12.13.24318927doi: medRxiv preprint 16 ‘I don't know which GP that referred me to the HUB. But I am thrilled that they 300 did and for what reason, I don't know. I don't know why they sent me there now 301 it could be because of my back’ (Participant 13) 302 Most participants indicated that their referral to CST OP was probably catalysed by 303 their reduced function, need to access physiotherapy, or frailty. 304 Older adults reported receiving varying levels of information about CST OP prior to 305 attending the service, ranging from verbal explanations from referrers to appointment 306 letters from CST OP, but participants generally described limited understanding from 307 their GPs or hospital doctors about CST OP's role in their care. A common 308 description provided to older adults by their GP was that CST OP was a ‘new 309 service’. 310 ‘Yes (GP), he explained it all that it was a new, what would you say, a new 311 program that they were starting up and that he asked me whether if I would 312 like to do it firstly’ (Participant 1). 313 Some older adults described accessibility challenges in attending CST OP, including 314 difficulties arranging transportation as they were reliant on others for transportation 315 and issues with parking at CST OP location. 316 ‘I never learned to drive so I don't drive so I’ve always have to get a friend to 317 drive me over or my son would drive me over’ (Participant 7). 318 Some participants described that, they had to travel outside their local community to 319 an urban setting to attend CST OP. One older adult described frustration that 320 geographical boundaries limited them attending their nearest CST OP team. 321 Theme 2: The CST OP team provided coordinated, comprehensive care and 322 built strong relationships with older adults. 323 This theme relates to older adults’ experiences of the CST OP team. They described 324 thorough assessments and quick access to medical testing, leading to timely 325 diagnoses when attending CST OP. This promptness of assessments and medical 326 testing was followed by well-planned, comprehensive care, and the strong 327 relationships formed with CST OP team members enhanced their overall experience 328 with the service. 329 All rights reserved. No reuse allowed without permission. preprint (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for thisthis version posted December 16, 2024. ; https://doi.org/10.1101/2024.12.13.24318927doi: medRxiv preprint 17 ’He (GP) couldn’t believe all that was checked out, with my like my blood work, 330 and everything was checked out and he got all the results, and they were all 331 within normal range and thank God I don’t have high blood pressure or low 332 blood pressure its quite normal’’ (Participant 12). 333 Older adults described that, they were impressed by the rapid access to diagnostics 334 including bone density scans, blood tests, head up tilt tests, memory assessments 335 and 24hour blood pressure monitors. These services and medical diagnostics 336 facilitated prompt diagnosis and effective management of their health complaints. 337 ‘’And what I was very impressed was immediately when I told them about the 338 hip and the fracture, they send me for a DEXA (dual energy X-ray 339 absorptiometry) scan which showed I had osteoporosis’’ (Participant 9). 340 In some cases, when results of these diagnostic test results were normal, it 341 reassured older adults or enhanced their confidence with managing their condition or 342 symptoms at home independently. 343 ‘Well naturally when you go over 80 not to mention going over 90, you're 344 nervous … when you get good news its very encouraging to keep going and to 345 fight and to keep, keep fighting and don't sit down and give in’ (Participant 8) 346 Older adults reported that the assessments and examinations conducted by the CST 347 OP team was very thorough. They felt that every aspect of their healthcare concerns 348 and needs was addressed in detail. 349 ‘I got an overhaul from head to toe. They didn't leave anything out else they 350 examined me every way … I found it very good now’ (Participant 9). 351 In contrast to other healthcare experiences older adults described that, there was no 352 time limits imposed when voicing their health concerns to the CST OP team. They 353 appreciated the opportunity to fully explain their issues without the feeling of being 354 rushed. The comprehensive nature of the assessment, along with the open dialogue 355 with the CST OP team, allowed the older adults to feel heard and understood in a 356 way that was distinct from their typical healthcare encounters. 357 ‘Oh yeah, you could tell them anything. You could tell them anything there was 358 no problem there’ (Participant 7). 359 All rights reserved. No reuse allowed without permission. preprint (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for thisthis version posted December 16, 2024. ; https://doi.org/10.1101/2024.12.13.24318927doi: medRxiv preprint 18 The positive communication with the CST OP team resulted in, older adults feeling 360 relaxed and comfortable which enabled them to share important information and 361 priorities. 362 ‘I don't know you're just feel comfortable you know, I felt comfortable in my 363 own skin whereas you go down to the doctor you get tensed up before you go 364 in’ (Participant 13). 365 Older adult’s descriptions of the CST OP team members and the relationships they 366 established with the team were universally positive. CST OP team members were 367 described as kind, generous, caring, nice, helpful, understanding, empathic and 368 concerned with older adults, leading to a comfortable assessment and intervention 369 process for older adults. 370 ‘It was their kindness and understanding and you know you can sit here like, 371 make sure I could sit down and was able to walk on my own and if not, they 372 were going to get a wheelchair’ (Participant 9). 373 Theme 3: CST OP intervention enabled older adults to better manage everyday 374 activities and long-term conditions, thereby improving their wellbeing. 375 This theme related to older adults’ description that intervention from CST OP 376 enabled them to better manage their long-term conditions and improved their ability 377 to complete activities and maintain independence at home. This ultimately led to 378 improved older adult emotional wellbeing. 379 Older adults described presenting to CST OP with a range of long-term conditions 380 and symptoms and concerns about their health that, impacted their ability to manage 381 at home. Older adults described how intervention and rehabilitation from CST OP 382 enabled them to better manage their long-term conditions and improved their ability 383 to complete activities and maintain independence at home. 384 ‘Yes, they did help me in in that way, like being far more confident, you know, 385 going up and down the stairs’ (Participant 9) 386 Older adults described that a medication review as a key component of the CST OP 387 intervention. Participants describe that in comparison to other healthcare services 388 they previously had accessed, detailed consideration was taken by CST OP of their 389 All rights reserved. No reuse allowed without permission. preprint (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for thisthis version posted December 16, 2024. ; https://doi.org/10.1101/2024.12.13.24318927doi: medRxiv preprint 19 medication regime. They described various changes to their medications following 390 this review which they attributed to various positive outcomes such as improved 391 symptom management (e.g. pain, high / low blood pressure and infections) and 392 better management of chronic conditions. For example, one participant described 393 following a change to their medication regime by CST OP it enabled effective 394 management of their palpitations leading to their increased independence at home. 395 ‘They put me on the tablet you know what I mean and the tablet slowed down 396 the palpitations so that I am very thankful for because, I mean I don't know 397 where I'd be now if because, it was nearly coming up my throat the palpitations 398 were going, the heart would take off if I walk from here and, I get breathless if I 399 walk to the sink and they found that so that I'm thankful for it’ (Participant 13) 400 Older adults valued home visits (a small number of older adults had home visits by 401 an OT) and provision of assistive devices, strategies, and exercise plans by the CST 402 OP team to manage long term conditions and maintain/ improve safety and 403 independence in daily activities. 404 ‘I did admit that it was difficult using the bath, which I use every night or most 405 nights. And I got the chair for the bath, they installed that for me, and I find 406 that is a marvellous help’ (Participant 10) 407 Older adults reported receiving clear, detailed exercise plans tailored to their 408 individual needs, with thorough explanations from the CST OP physiotherapist. Older 409 adults greatly valued these personalised exercise plans which enabled them to 410 continue the exercise plans on their own after discharged from the service, and 411 ultimately enabled them to maintain their mobility and independence. Other reported 412 benefits of exercise programs included improved quality of life and reduced pain. 413 ‘I found that I kept doing my exercises and that I am walking an awful lot better, 414 and my quality of life has improved’ (Participant 12) 415 One participant described how they were able to achieve their rehabilitation goal of 416 being able to walk independently with a walking stick after their intervention with the 417 CST OP service. 418 All rights reserved. No reuse allowed without permission. preprint (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for thisthis version posted December 16, 2024. ; https://doi.org/10.1101/2024.12.13.24318927doi: medRxiv preprint 20 ‘Well as I said they got me back walking again properly, because I couldn't 419 walk before, I’m alright now walking … She had me walking round first of all in 420 a frame and then at the end of it, she had me onto a stick’ (Participant 6) 421 One participant highlighted specific health benefits of CST OP intervention, noting 422 how exercises from the CST OP Speech and Language Therapist effectively 423 addressed their swallowing issue. 424 ‘She was telling me how to chew my food and that type of thing well…..when I 425 was eating at times, I'd get a cough you know, and she dealt with that and 426 dealt with it very capably’ (Participant 7) 427 Older adults described positive psychological, well-being changes along with 428 improved quality of life following their intervention with CST OP. In many cases, 429 improvements in their function led to improved emotional well-being. Within this 430 study, older adults provided a multitude of examples of returning to their usual life 431 activities/hobbies and increased independence/improved performance in these 432 activities due to the intervention from the CST OP team. One participant described 433 intervention from CST OP as transformative. 434 ‘It was like, it was like you know it (CST OP) would nearly put back the life back 435 into you’ (Participant 13) 436 Older adults described new feelings of confidence and liberation after their 437 intervention with the CST OP team. Older adults gave examples that intervention 438 from CST OP enabled them to return to activities that, they had stopped prior to CST 439 OP such as driving to visit their family members or being able to do their stairs at 440 home. 441 ‘But shortly after the, my final visit, I drove to Dublin, you know, and I found 442 that that was very liberating. Actually, I can do it again now you know’ 443 (Participant 9) 444

445 Summary of main findings 446 This qualitative descriptive study aimed to explore older adults’ experiences of the 447 CST OP service in the Mid-West of Ireland. From interviews with 13 participants 448 All rights reserved. No reuse allowed without permission. preprint (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for thisthis version posted December 16, 2024. ; https://doi.org/10.1101/2024.12.13.24318927doi: medRxiv preprint 21 attending the service we found that, older adults highly valued the service. However, 449 many faced accessibility barriers and were unsure of what to expect from the service 450 prior to participating (theme 1). Older adults perceived that the CST OP team 451 delivered coordinated, and comprehensive care, developing strong relationships with 452 them (theme 2). Importantly, the CST OP intervention was empowering for the older 453 adults, enabling them to better manage their long-term conditions and maintain their 454 independence living at home. Overall, the CST OP service was experienced by older 455 adults to have a positive impact on their functional ability and emotional well-being 456 (theme 3). 457 Comparison with existing literature 458 Our findings offer a comprehensive account of older adults’ experiences with a new 459 model of community-based, integrated care for older adults in Ireland. This 460 demographic is often underrepresented within clinical research, highlighting a crucial 461 need for health research that includes this population cohort (Thake et al., 2017). 462 Notably, previous qualitative research on integrated care experiences has largely 463 overlooked the perspectives of older adults (Karascony et al., 2022). Within 464 healthcare research, older adults aged 85 years and older are often referred to as 465 the ‘oldest old’ (Gu & Dupre, 2021) and research on preventative interventions for 466 this population is limited (Escourrou et al., 2022). Within this study, participants 467 ranged in age from 76 to 95 years with a mean age of 85 years. Our findings provide 468 new knowledge for decision makers and policy makers on the integrated care 469 experiences and perceptions of an ‘oldest old’ demographic cohort. 470 Most participants within this study required assistance from family or others for 471 transportation to CST OP sites and therefore faced accessibility issues in attending 472 the service. This finding is keeping with data from the Irish Longitudinal Study on 473 Ageing (TILDA) which revealed that, as older adults age in Ireland, they are less 474 likely to drive and become reliant on others for transport due to poor public 475 transportation (Donoghue et al., 2017). The WHO has recommended that integrated 476 care services should be offered close to where people live (WHO, 2018). Additionally, 477 recent qualitative systematic review found that older adult’s express greater comfort 478 and confidence when they can receive integrated care services within their own 479 homes (Karascony et al., 2022). Provision of transport or provision of home-based 480 All rights reserved. No reuse allowed without permission. preprint (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for thisthis version posted December 16, 2024. ; https://doi.org/10.1101/2024.12.13.24318927doi: medRxiv preprint 22 services are two potential solutions both with potential cost and acceptability 481 implications. Integrated care has been found to likely reduce cost however, the 482 evidence varies largely and is only of moderate quality (Rocks et al., 2020). A review 483 of cost-effectiveness of homecare services compared to in-hospital care for adults 484 concluded that, homecare interventions are likely to be cost-saving and as effective 485 as care in a hospital (Curioni et al., 2023). However, little is known about how well 486 public transport systems provide older adults with access to key destinations in 487 various regions around the world (Ravensbergen et al., 2022) thus, further research 488 to explore transport interventions and provision of CST OP services in the home 489 environment are warranted. 490 A primary finding from this study was that older adults valued the comprehensive 491 CST OP assessment. CGA has been extensively researched and demonstrated to 492 yield quantifiable positive healthcare outcomes for older adults across a variety of 493 settings, including primary care (Pilotto et al., 2017; Garrard et al., 2020; Welsh et al., 494 2014). The use of CGA within integrated care services for older adults is also actively 495 promoted by the WHO (WHO, 2018). Our findings indicate that older adults valued 496 CGA as it effectively addressed their healthcare concerns, managed their presenting 497 symptoms, and facilitated timely access to necessary interventions and therapies. 498 These findings align with those of a recent qualitative evidence synthesis, which 499 reported that older adults who underwent a CGA in community-based settings 500 experience it positively as it promotes a holistic approach in addressing their needs 501 (Hayes et al., 2023). 502 Medication reviews are one of the most common elements of integrated care models 503 for older adults (Briggs et al, 2018) and unsurprisingly are core to the CST OP model. 504 We found older adults experienced medication review as leading to significant 505 adjustments and positive outcomes including improved symptom management. A 506 recent cohort study by Payen and colleagues found that combining a medication 507 review with an integrated care approach was linked to a reduction in the number of 508 hospital readmissions within 30 days for older adults (Payen et al., 2022). Given that 509 polypharmacy is common among older adults due to multiple co-mobilities this group 510 are at risk of inappropriate prescriptions or adverse drug effects (Beuscart et al., 511 2021). Medication safety has been identified as a key area for improvement for all 512 healthcare settings in line with WHO recommendations (HIQA, 2019). 513 All rights reserved. No reuse allowed without permission. preprint (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for thisthis version posted December 16, 2024. ; https://doi.org/10.1101/2024.12.13.24318927doi: medRxiv preprint 23 In contrast with the broader literature on integrated care, findings do not provide rich 514 information on older adult’s experiences of care-coordination or communication 515 between professionals, their involvement in care planning and decision-making, or if 516 there were any gaps or fragmentation in providers/services that disrupted their care 517 experience. This may reflect the differing priorities of heath care between older 518 adults and healthcare researchers/healthcare providers. 519 A case management approach is being embedded with CST OP services (Barry et 520 al., 2021). Case management is a role undertaken by a health or social care 521 professional, supported by a wider team with responsibilities including assessment, 522 care planning, and co-ordination of care to meet the needs the older adult (Sadler et 523 al., 2023). Within this study, older adults described meeting the same nurse or 524 professional from the CST OP during their intervention which may have been an 525 healthcare professional working within a case manager role. Of note, a recent 526 Cochrane review examining case management programmes for older people living 527 with frailty in the community found they may make little or no difference to patient 528 and service outcomes and care-related costs (Sadler et al., 2023). Therefore, further 529 research is required on the role and effectiveness of case management within CST 530 OP model of care. 531 Communication with healthcare providers in integrated care service is of critical 532 importance as older adults typically define their perspectives towards integrated care 533 with respect to the relational, informational and organisational aspects of care 534 (Lawless et al., 2020). We found that older adults had positive experiences 535 communicating with CST OP teams, such as feeling unhurried, feeling comfortable 536 sharing information, and receiving clear information/ instructions from team members. 537 This is important as the quality of healthcare provider communication with older 538 adults can impact their trust and satisfaction with their healthcare provider, impacting 539 overall health and outcomes for older adults (Birkhäuer et al., 2017). Additionally, 540 older adults are more likely to talk about their healthcare problems when healthcare 541 professionals employ an open style of communication and listen to their opinions in 542 relation to their care (Gibney & Moore, 2018) which aligns with the process of CGA 543 which underpins the CST OP model of care. 544 545 All rights reserved. No reuse allowed without permission. preprint (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for thisthis version posted December 16, 2024. ; https://doi.org/10.1101/2024.12.13.24318927doi: medRxiv preprint 24 546 Strengths and Limitations: 547 This is the first study to explore older adults’ experiences of the CST OP service 548 model in Ireland. We acknowledge the lack of participant diversity, as all recruited 549 participants identified as ‘White Irish’. However, our participant profile sample is 550 reflective of the 2022 national Census which identified that, most older adults aged 551 85 years and older identify their ethnicity as being White Irish (CSO, 2024). Ease 552 and comfort throughout interview process of participants was maximised by 553 conducting interviews in participants’ homes and having caregivers present, when 554 requested by participants. However, it is possible that the presence of caregivers 555 may have influenced participant responses to interviewer questions. Additionally, 556 some older adults that had intervention with CST OP were also accessing multiple 557 healthcare services, thus had difficulty in distinguishing their intervention with CST 558 OP from other healthcare encounters. 559 This research study has a sample size of 13 and data saturation was achieved. The 560 qualitative analysis was enriched by the researchers prolonged engagement with the 561 data, rigorous approach to coding and adherence to principles of investigator 562 triangulation during analysis. The concept of this study was informed by an 563 established Public and Patient Involvement (PPI) stakeholder panel of older adults 564 and family caregivers. Additionality, semi-structured interviews were underpinned by 565 rigorous literature review and was piloted with an older adult to develop and refine 566 topic guide. A further strength of the study was that the research team were from 567 different healthcare backgrounds, with diverse clinical and research experience. 568

569 This study offers in-depth qualitative exploration of older adults’ experience of the 570 CST OP service in the Midwest region of Ireland. Our findings indicate that older 571 adults highly valued the CST OP service, however, were uncertain of what to expect 572 prior to engaging with the service and faced some accessibility barriers attending the 573 hubs (Theme 1); the CST OP team delivered coordinated, comprehensive care and 574 fostered strong relationships (Theme 2); and the CST OP intervention enabled older 575 adults manage daily activities and long-term conditions, enhancing their well-being 576 (Theme 3). 577 All rights reserved. No reuse allowed without permission. preprint (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for thisthis version posted December 16, 2024. ; https://doi.org/10.1101/2024.12.13.24318927doi: medRxiv preprint 25 Our findings underscore the value of CGA in community-based care to meet the 578 needs of older adults. Further research is needed on solutions to access barriers, as 579 well as further evaluation of older adults' experiences with case management and 580 care coordination within the CST OP service model. 581 ---------------------------------------------------------------------------------------------------------------- 582 Abbreviation List: 583 ICPOP: Integrated Care Programme for older persons 584 CST: Community Specialist team 585 CGA: Comprehensive Geriatric Assessment 586 WHO: World Health Organisation 587 ADL: Activities of Daily Living 588 MDT: Multidisciplinary team 589 ACSH: Ambulatory Care Specialist Hub 590 GP: General Practitioner 591 PT: Physiotherapy 592 OT: Occupational Therapy 593 ANP: Advanced Nurse Practitioner 594 SLT: Speech and Language Therapy 595 CNS: Clinical Nurse Specialist 596 CM: Case Manager 597 MT: Medical Team 598 ED: Emergency Department 599 HSE: Health Service Executive 600 MDT: Muli-Disciplinary Team Members 601 DEXA: Dual energy X-ray absorptiometry 602 All rights reserved. No reuse allowed without permission. preprint (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for thisthis version posted December 16, 2024. ; https://doi.org/10.1101/2024.12.13.24318927doi: medRxiv preprint 26 Ethics approval and consent to participate. 603 Ethical approval was gained from the HSE Mid-Western Regional Hospital Ethics 604 Committee at the University Hospital of Limerick (Rec Ref:116/2021). 605 Availability of data and materials 606 The datasets from this research study are not readily available to protect participants 607 confidentiality. Requests to access anonymised partial datasets can be made by 608 contact the lead author. 609 Authors’ contribution 610 BC was responsible for conceptualisation of the study, design of the work, analysis, 611 and interpretation of the data, and writing the initial draft of the manuscript. KR, AG, 612 RG, MM and CF were responsible for conceptualisation of the study, design of the 613 work, analysis and interpretation of the data, supervision, and revised the manuscript 614 from a critical perspective to enhance its contents. All the authors have read and 615 approved the final draft of the manuscript. 616 Funding 617 This research is funded through the Health Research Board (HRB) of Ireland (Health 618 Research Board, Grattan House 67-72 Lower Mount Street, Dublin 2, D02 H6380 619 under the HRB Research Leader Award RL-2020-010 and was conducted as part of 620 the SPHeRE programme. The funder had no role in this study. 621 Consent for publication. 622 Not applicable 623 Competing interests 624 The authors declare that they have no competing interests. 625

626 The research team would like to acknowledge the participants recruited in this study 627 for their time given to complete this study. 628

List 629 All rights reserved. No reuse allowed without permission. preprint (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for thisthis version posted December 16, 2024. ; https://doi.org/10.1101/2024.12.13.24318927doi: medRxiv preprint 27 1. Barry, S., Fhallúin, M.N., Thomas, S., Harnett, P.J. and Burke, S. (2021) 630 Implementing Integrated Care in Practice-Learning from MDTs Driving the 631 Integrated Care Programme for Older Persons in Ireland, International Journal of 632 Integrated Care, 21(1), pp.15. 633 634 2. Baxter, S., Johnson, M., Chambers, D., Sutton, A., Goyder, E. and Booth, A. 635 (2018) The effects of integrated care: a systematic review of UK and international 636 evidence, BMC Health Serv Res, 18, 350. 637 638 3. Beuscart, J.B., Pelayo, S., Robert, L., Thevelin, S., Marien, S., Dalleur, O. (2021) 639 Medication review and reconciliation in older adults, Eur Geriatr Med, 12(3). pp. 640 499-507. 641 642 4. Birkhäuer, J., Gaab, J., Kossowsky, J., Hasler, S., Krummenacher, P., Werner, C. 643 and Gerger, H. (2017) Trust in the health care professional and health outcome: 644 a meta-analysis, PloS one, 12(2). 645 646 647 5. Briggs, A.M., Valentijn, P.P., Thiyagarajan, J.A., Araujo de Carvalho, I. (2018) 648 Elements of integrated care approaches for older people: a review of reviews, 649 BMJ, 8(4). 650 651 6. British Geriatric Society. (2024) Joining the dots: A blueprint for preventing and 652 managing frailty in older people, London: British Geriatric Society, Available: 653 https://www.bgs.org.uk/resources/joining-the-dots-chapter-one-about-this-report 654 [Accessed 12 November 2024]. 655 656 7. Bruan.V. and V. Clarke. (2019) Qualitative Research in Sport, Exercise and 657 Health, 11 (4), pp. 589-597. 658 659 660 8. Condon, B., Griffin, A., Fitzgearld, C., Shanahan, E., Glynn, L., O’Connor, M., 661 Hayes, C., Manning, M., Galvin, R., Leahy, A. and Robinson, K. (2024) Older 662 All rights reserved. No reuse allowed without permission. preprint (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for thisthis version posted December 16, 2024. ; https://doi.org/10.1101/2024.12.13.24318927doi: medRxiv preprint 28 adults experience of transition to the community from the emergency department: 663 a qualitative evidence synthesis, BMC Geriatrics, 24, 233. 664 665 9. Central Statistics Office. (2024) Census 2022 Profile 5 - Diversity, Migration, 666 Ethnicity, Irish Travellers & Religion, Cork: Central Statistics Office, Available: 667 https://www.cso.ie/en/releasesandpublications/ep/p-cpp5/census2022profile5-668 diversitymigrationethnicityirishtravellersreligion/ethnicgroupbackground/ 669 [Accessed 22 November 2024]. 670 671 10. Curioni, C., Silva, A. C., Damião, J., Castro, A., Huang, M., Barroso, T., Araujo, D. 672 and Guerra, R. (2023) The Cost-Effectiveness of Homecare Services for Adults 673 and Older Adults: A Systematic Review, Int J Environ Res Public Health, 20(4). 674 675 11. Daly, J., Willis, K., Small, R., Green, J., Welch, N., Kealy, M. and Hughes, E. 676 (2007) A hierarchy of evidence for assessing qualitative health research, Journal 677 of clinical epidemiology, 60(1), pp.43-49. 678 679 12. Donoghue, O., Orr, J., Leahy, S. and Kenny, R.A. (2017) Transport patterns in 680 community-dwelling adults aged 50 years and over in Ireland, Dublin: The Irish 681 Longitudinal Study on Ageing, Available: 682 https://tilda.tcd.ie/publications/reports/pdf/Report_TransportPatterns.pdf 683 [Accessed 30 June 2024]. 684 685 686 13. Escourrou., E., Laurent, S., Leroux, J., Oustric, S. and Gardette, V. (2022) The 687 shift from old age to very old age: an analysis of the perception of aging among 688 older people, BMC Prim Care, 23 (3). 689 690 14. Fitzgearld, A., McDonnell, Ó., Daly, B., Dukelow, T., Jennings, A. and Foley, T. 691 (2023) The barriers and enablers to an effective integrated care programme for 692 older persons: a qualitative study, Age and Ageing, 52. 693 694 All rights reserved. No reuse allowed without permission. preprint (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for thisthis version posted December 16, 2024. ; https://doi.org/10.1101/2024.12.13.24318927doi: medRxiv preprint 29 15. Garrard, J. W., Cox, N. J., Dodds, R. M., Roberts, H. C. and Sayer, A. A. (2020) 695 Comprehensive geriatric assessment in primary care: a systematic review, Aging 696 Clin Exp Res, 32, pp.197-205. 697 698 16. Gibney, S. and Moore, T. (2018) Older Patients' Views of Health Care 699 Interactions in Ireland, Health literacy research and practice, 15(2), pp.180-191. 700 701 17. Gu, D and Dupre, M.E. (2019) "Encyclopaedia of Gerontology and Population 702 Aging" . Faculty Bookshelf. 138.D. Gu, M.E. Dupre (Eds.) gerontology and 703 population aging, Springer, Cham (2021), pp. 3637-3653. 704 705 18. Hayes, C., Fitzgearld, C., O., Condon, B., Leahy, A., O’Connor, M., Manning, M., 706 Griffin, A., Glynn, L., Robinson, K. and Galvin, R. (In press) Community Specialist 707 Teams for Older Persons (CST OP) at risk of or living with frailty in Ireland: a 708 prospective cohort study of a new model of integrated care for community 709 dwelling older adults. - in press. 710 711 19. Haase, T. and Pratschke, J (2022) Pobal Haase and Pratschke Deprivation 712 Indices, An Pobal: Dublin, Available: https://www.pobal.ie/pobal-hp-deprivation-713 index/ [Accessed 29 November 2024]. 714 715 716 20. Hayes, C., Fitzgearld, C., O’Shaughnessy, Í., Condon, B., Leahy, A., O’Connor, 717 M., Manning, M., Griffin, A., Glynn, L., Robinson, K. and Galvin, R. (2023) 718 Exploring stakeholders’ experiences of comprehensive geriatric assessment in 719 the community and out-patient settings: a qualitative evidence synthesis, BMC 720 Primary Care, 24, 274. 721 722 21. Health Service Executive. (2024a) Community care improving health outcomes 723 and experiences for patients across Ireland, Dublin: Health Service Executive, 724 Available: https://about.hse.ie/news/community-care-improving-health-outcomes-725 experiences-patients-across-ireland/ [Accessed 12th September 2024]. 726 727 All rights reserved. No reuse allowed without permission. preprint (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for thisthis version posted December 16, 2024. ; https://doi.org/10.1101/2024.12.13.24318927doi: medRxiv preprint 30 22. Health Service Executive (2024b) Regional Population Profile Health Region: 728 Mid-West, Limerick: Department of Public Health Midwest, Available: 729 https://www.hse.ie/eng/about/who/healthwellbeing/knowledge-730 management/health-intelligence-files/hr-mid-west-profile-census-2022.pdf 731 [Accessed 30 June 2024]. 732 733 23. Health Information and Quality Authority. (2019) Guide to HIQA’s Medication 734 Safety Monitoring Programme against the National Standards for Safer, Better 735 Healthcare in 2019, Dublin: Health Information and Quality Authority, Available: 736 https://www.hiqa.ie/sites/default/files/2019-01/Medication-Safety-Monitoring-737 Programme-Guide-2019.pdf [Accessed 1 November 2024]. 738 739 24. Hennick, M. and Kaiser, B.N. (2022) Sample sizes for saturation in qualitative 740 research: A systematic review of empirical tests, Social Science & Medicine, 292. 741 742 25. ICPOP Steering Group. (2017) Making A Start in Integrated Care for Older 743 Persons: A Practical Guide to the Local Implementation of Integrated Care 744 Programmes for Older Persons, Dublin: Health Service Executive, Available: 745 https://www.hse.ie/eng/services/publications/clinical-strategy-and-programmes/a-746 practical-guide-to-the-local-implementation-of-integrated-care-programmes-for-747 older-persons.pdf [Accessed 12 November 2024]. 748 749 750 26. Karascony, S., Merl, H., O'Brien, J., Maxwell, H., Andrews, S., Greenwood, M., 751 Rouhi, M., McCann, D. and Stirling, C. (2022) What are the Clinical and Social 752 Outcomes of Integrated Care for Older People? A Qualitative Systematic Review, 753 International Journal of Integrated Care, 22(3). 754 755 27. Kim, H., Sefcik, J.S. and Bradway, C. (2017) Characteristics of qualitative 756 descriptive studies: A systematic review , Research in nursing & health, 40(1), 757 pp.23-42. 758 759 All rights reserved. No reuse allowed without permission. preprint (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for thisthis version posted December 16, 2024. ; https://doi.org/10.1101/2024.12.13.24318927doi: medRxiv preprint 31 28. Kirvalidze, M., Boström, A.M., Liljas, A., Doheny, M., Hendry, A., McCormack, B., 760 Fratiglioni, L., Ali, S., Ebrahimi, Z., Elmståhl, S. and Eriksdotter, M. (2024) 761 Effectiveness of integrated person‐ centered interventions for older people's care: 762 Review of Swedish experiences and experts’ perspective, Journal of Internal 763 Medicine, 295(6), pp.804-824. 764 765 29. Lawless, M.T., Marshall, A., Mittinty, M.M. and Harvey, G. (2020) What does 766 integrated care mean from an older person's perspective? A scoping review, BMJ 767 open, 10(1). 768 769 30. Liljas, A.E.M., Brattström, F., Burström, B., Schön, P., Agerholm, J. (2019) Impact 770 of Integrated Care on Patient-Related Outcomes Among Older People - A 771 Systematic Review, Int J Integr Care, 19 (3). 772 773 31. Lumivero. (2024) NVivo (Version 14) www.lumivero.com. 774 775 32. Morgan, D. L. and Nica, A. (2020) Iterative Thematic Inquiry: A New Method for 776 Analyzing Qualitative Data, International Journal of Qualitative Methods, 19. 777 778 33. Morse, J. M. (2015) Critical analysis of strategies for determining rigor in 779 qualitative inquiry, Qualitative Health Research, 25(9), pp. 1212–1222. 780 781 34. Payen, A., Godard-Sebillotte, C., Sourial, N., Soula, J., Verloop, D., Defebvre, 782 M.M., Dupont, C., Dambre, D., Lamer, A.and Beuscart, J.B (2023) The impact of 783 including a medication review in an integrated care pathway: A pilot study, Br J 784 Clin Pharmacol, 89(3), pp. 1036-104. 785 786 35. Pilotto, A., Cella, A., Pilotto, A., Daragjati, J., Veronese, N., Musacchio, C., Mello, 787 A.M., Logroscino, G., Padovani, A., Prete, C. and Panza, F. (2017) Three 788 decades of comprehensive geriatric assessment: evidence coming from different 789 healthcare settings and specific clinical conditions, Journal of the American 790 Medical Directors Association, 18(2). 791 792 All rights reserved. No reuse allowed without permission. preprint (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for thisthis version posted December 16, 2024. ; https://doi.org/10.1101/2024.12.13.24318927doi: medRxiv preprint 32 36. Ravensbergen, L., Van Liefferinge, M., Isabella, J., Merrina, Z. and El-Geneidy, A. 793 (2022) Accessibility by public transport for older adults: a systematic review, 794 Journal of Transport Geography, 103. 795 796 797 37. Rocks, S., Berntson, D., Gil-Salmerón, A., Kadu, M., Ehrenberg, N., Stein, V and 798 Tsiachristas, A. (2020) Cost and effects of integrated care: a systematic literature 799 review and meta-analysis, Eur J Health Econ, 21, pp.1211-1221. 800 801 38. Rockwood, K., Song, X., MacKnight, C., Bergman, H., Hogan, D.B., McDowell, I. 802 and Mitnitski, A. (2005) A global clinical measure of fitness and frailty in elderly 803 people, CMAJ, 173(5), pp. 489-495. 804 805 39. Sadler, E., Khadjesari, Z., Ziemann, A., Sheehan, K.J., Whitney, J., Wilson, D., 806 Bakolis, I., Sevdalis, N., Sandall, J., Soukup, T., Corbett, T., Gonçalves-Bradley, 807 D.C. and Walker, D.M. (2023) Case management for integrated care of older 808 people with frailty in community settings, Cochrane Database of Systematic 809 Reviews, 5 (5). 810 811 40. Sadler, E., Potterton, V., Anderson, R., Khadjesari, Z., Sheehan, K., Butt, F., 812 Sevdalis, N. and Sandall, J. (2019) Service user, carer and provider perspectives 813 on integrated care for older people with frailty, and factors perceived to facilitate 814 and hinder implementation: A systematic review and narrative synthesis, PloS 815 one, 14(5). 816 817 41. Sheehan, A. and O’Sullivan, R. (2020) Ageing and Public Health – an overview 818 of key statistics in Ireland and Northern Ireland (Executive Summary), Dublin: 819 Institute of Public Health, Available:https://www.publichealth.ie/reports/ageing-820 and-public-health-overview-key-statistics-ireland-and-northern-ireland [Accessed 821 14 November 2024]. 822 823 824 All rights reserved. No reuse allowed without permission. preprint (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for thisthis version posted December 16, 2024. ; https://doi.org/10.1101/2024.12.13.24318927doi: medRxiv preprint 33 42. Sheaff, R., Halliday, J., Byng, R., Øvretveit, J., Exworthy, M., Peckham, S. and 825 Asthana, S. (2017) Bridging the discursive gap between lay and medical 826 discourse in care coordination, Sociology of Health & Illness, 39(7), pp.1019-827 1034. 828 829 43. Thake, M. and Lowry, A. (2017) A systematic review of trends in the selective 830 exclusion of older participant from randomised clinical trials, Archives of 831 Gerontology and Geriatrics, 72, pp. 99-102. 832 833 44. Tong, A., Sainsbury, Y, P. and Craig, J. (2007) Consolidated criteria for reporting 834 qualitative research (COREQ): a 32-item checklist for interviews and focus 835 groups, Int J Qual Health Care, 19(6), pp. 349-57. 836 837 45. Uittenbroek, R. J., Kremer, H. P. H., Spoorenberg, S. L. W., Reijneveld, S. A. and 838 Wynia, K. (2017) Integrated Care for Older Adults Improves Perceived Quality of 839 Care: Results of a Randomized Controlled Trial of Embrace, J Gen Intern Med, 840 32 (5), pp. 516-523. 841 842 843 46. Welsh, T.J., Gordon, A.L. and Gladman, J.R. (2014) Comprehensive geriatric 844 assessment--a guide for the non-specialist, International Journal of Clinical 845 Practice, 68(3), pp.290-293. 846 847 47. World Health Organization. (2015a) World report on ageing and health, Geneva: 848 World Health Organization, Available from: 849 http://www.who.int/ageing/publications/world-report-2015/en/ [Accessed 1st 850 August 2024]. 851 852 48. World Health Organization. (2015b) WHO global strategy on integrated people-853 centred health services 2016-2026 Executive Summary Placing people and 854 communities at the centre of health services, Geneva: World Health Organization, 855 Available: https://interprofessional.global/wp-content/uploads/2019/11/WHO-856 2015-Global-strategy-on-integrated-people-centred-health-services-2016-857 2026.pdf [Accessed 1st August 2024]. 858 All rights reserved. No reuse allowed without permission. preprint (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for thisthis version posted December 16, 2024. ; https://doi.org/10.1101/2024.12.13.24318927doi: medRxiv preprint 34 859 860 49. World Health Organization. (2018) Integrated care for older people: realigning 861 primary health care to respond to population ageing, Geneva: World Health 862 Organization, Available: https://www.who.int/publications/i/item/WHO-HIS-SDS-863 2018.44 [Accessed 1st August 2024]. 864 865 50. Yan Wang, N., Liu, X., Kong, X., Sumi, Y., Chhetri, J.K., Hu, L., Zhu, M., Kang, L., 866 Liang, Z., Ellis, J.W. and Shi, L. (2024) Implementation and impact of the World 867 Health Organization integrated care for older people (ICOPE) program in China: 868 a randomised controlled trial, Age and ageing, 53(1). 869 870 871 872 873 874 875 876 877 878 879 880 881 882 883 884 885 All rights reserved. No reuse allowed without permission. preprint (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for thisthis version posted December 16, 2024. ; https://doi.org/10.1101/2024.12.13.24318927doi: medRxiv preprint 35 886 887 Supplementary File 1 888 COREQ Checklist 889 890 Topic Item No Guide Questions/description Reported on page no Domain 1: Research team and reflexivity Personal Characteristics Interviewer/facilitator 1 Which author/s conducted the interview or focus group? 8 Credentials 2 What are the researcher credentials? E.g. PhD,MD 8 Occupation 3 What was their occupation at the point of their study? 8 Gender 4 Was the researcher male or female? 8 Experience and training 5 What experience or training did the researcher have? 8,10 Relationship with participants Relationship established 6 Was a relationship established prior to study commencement? 8,9 Participant knowledge of the interviewer 7 What did the participants know about the researcher? e.g. personal goals, reasons for doing the research. 8,9 Interviewer characteristics 8 What characteristics were reported about the interviewer/facilitator? e.g. Bias, assumptions, reasons and interests in the research topic. 8 Domain 2: Study Design Theoretical framework Methodological orientation and Theory 9 What methodological orientation was stated to underpin the study? e.g. grounded theory, 4 All rights reserved. No reuse allowed without permission. preprint (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for thisthis version posted December 16, 2024. ; https://doi.org/10.1101/2024.12.13.24318927doi: medRxiv preprint 36 discourse analysis, discourse analysis, ethnography, phenomenology, content analysis Participant selection Sampling 10 How were the participants selected? e.g. purposive, convenience, consecutive, snowball 8

of approach 11 How were participants approached? e.g. face- to-face, telephone, mail. email 8,9 Sample size 12 How many participants were in the study? 11 Non-participation 13 How many people refused to participate or dropped out? Reasons? 11 Setting Setting of data collection 14 Where was the data collected? e.g. home, clinic, workplace 8 Presence of non- participants 15 Was anyone else present besides the participants and researchers? 8 Description of sample 16 What are the important characteristics of the sample? e.g. demographic data, date. 12 Data collection Interview guide 17 Were questions, prompts, guides provided by the authors? Was it pilot tested? Supplementary File 2 Repeat interviews 18 Were repeat interviews carried out? If yes, how many? 9 Audio/visual recording 19 Did the research use audio or visual recording to collect the data? 9 Field notes 20 Were filed notes made during and/or after the interviewer or focus group? 9 Duration 21 What was the duration of interviews of focus groups? 12 Data saturation 22 Was data saturation discussed? 9 Transcripts 23 Were transcripts returned to participants for comment and/or correction? 9 Domain 3: analysis and findings Data analysis All rights reserved. No reuse allowed without permission. preprint (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for thisthis version posted December 16, 2024. ; https://doi.org/10.1101/2024.12.13.24318927doi: medRxiv preprint 37 Number of data coders? 24 How many data coders coded the data? 10 Description of the coding tree 25 Did authors provide a description of the coding tree? 10 Derivation of themes 26 Were themes identified in advance or derived from the data? 9,10 Software 27 What software, if applicable, was used to manage the data? 10 Participant checking 28 Did participants provide feedback on the findings? 10 Reporting Quotations presented 29 Were participants quotations presented to illustrate the themes/findings? Was each quotation identified? e.g. participant number 13-18 Data and findings consistent 30 Was there consistency between the data presented and the findings? 13-18 Clarity of major themes 31 Were major themes clearly presented in the findings? 13-18 Clarity of minor themes 32 Is there a description of diverse cases or

of minor themes? 13-18 891 892 893 894 895 896 Supplementary File 2 897 Topic Guide 898 Main Theme: At the Ambulatory Care Hub 899 1. Why did you initially attend the Ambulatory Care Hub (ACH)? 900 All rights reserved. No reuse allowed without permission. preprint (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for thisthis version posted December 16, 2024. ; https://doi.org/10.1101/2024.12.13.24318927doi: medRxiv preprint 38 2. What did you know about the team or the service before you went? Did you 901 know why you were there? (Understand the role of the ACH in your care vs 902 for e.g., GP care) 903 3. What was your experience in attending the ACH? Could you describe it for 904 me? (Travel, transport, waiting room, space, meals, length of time, parking). 905 4. Who did you see in the ACH? (Different team members) 906 5. Did each team member explain their role in your care? 907 6. How many visits did you have to the ACH? 908 Main Theme: Delivery of care 909 1. Could you describe for me what your experience of the 910 care/intervention/therapy delivered by the ACH? 911 2. Did you have a say in your treatment plan? (Goal – setting) 912 3. During your sessions with the team, did anybody talk how to manage different 913 tasks at home? 914 4. Were you happy with the length/time frame of input from the ACH? Did you 915 anyone ask your preferences? 916 5. Could you describe for me where your sessions took place, and did you have 917 any preference where your care was delivered? 918 6. Did you feel you were repeating information to different team members – was 919 there any links with your GP / other healthcare providers – try to draw on 920 examples from their own care. 921 Main Theme: Communication and discharge. 922 1. Could you explain to me your communication with the team, did they provide 923 you with mostly verbal or written information? Did you get all the right 924 information you needed? 925 2. Did you feel that you were ready to be discharged from the team? How was 926 this communicated to you? 927 3. How are you managing now at home, did the input from ACH impact your 928 ability to complete daily tasks? 929 4. Based on your experience, do you have suggestions on how the team could 930 help you better or be developed for other older adults? 931 All rights reserved. No reuse allowed without permission. preprint (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for thisthis version posted December 16, 2024. ; https://doi.org/10.1101/2024.12.13.24318927doi: medRxiv preprint 39 5. Has anything been missed from your care – are you waiting for any 932 appointments or has there been any miscommunication. 933 934 935 936 All rights reserved. No reuse allowed without permission. preprint (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for thisthis version posted December 16, 2024. ; https://doi.org/10.1101/2024.12.13.24318927doi: medRxiv preprint