Chinese Community-dwelling Older Adults’ Expectations regarding the Delivery of Integrated Care through Case Managers: A Mixed Methods Study Protocol

Chinese Community-dwelling Older Adults’ Expectations regarding the Delivery of Integrated Care through Case Managers: A Mixed Methods Study Protocol | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Study protocol Chinese Community-dwelling Older Adults’ Expectations regarding the Delivery of Integrated Care through Case Managers: A Mixed Methods Study Protocol Yuanyuan Zhao, Yuehua Tu, Hua Zhu This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4901154/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background The rising prevalence of chronic diseases among older adults in China calls for a more robust and efficient healthcare system. The current system, being fragmented and insufficient, fails to deliver comprehensive care for chronic diseases. There is a pressing need for tailored and integrated care solutions for older adults, which would facilitate resource sharing, improve access to advanced facilities, provide expert guidance, and ensure safe and effective care for those with multiple comorbidities. Methods Employing the PRISMA model recommended by the World Health Organization, this study suggests the use of a case manager to improve the delivery of publicly funded healthcare in the community. An exploratory sequential mixed methods approach will be implemented to investigate the acceptability of the PRISMA integrated care model and to identify the realistic needs, expectations, and associated sociodemographic characteristics of Chinese community-dwelling older adults respectively. An evidence-based integrated care model will be captured that can optimise healthcare delivery. Discussion By incorporating elements from the PRISMA model and considering the specific expectations of older adults, this study strives to promote integrated care through a centralised point of access managed by a case manager. This approach addresses significant gaps in the current healthcare provision and aims to improve the quality, accessibility, and efficiency of services, thereby improving care for the community. The findings of this study have the potential to inform policy decisions, guide the implementation of integrated care delivery, and ultimately improve health outcomes and the quality of life for older adults in China. Protocol Registration: The study protocol has been registered on osf.io (Registration DOI: https://doi.org/10.17605/OSF.IO/825AH ). Healthcare Case Manager Chronic Diseases Older Adults Community China Figures Figure 1 Background The National Bureau of Statistics has revealed that the ageing population in China, aged 60 and above, has exceeded 290 million by the end of 2023, accounting for approximately 21.1% of the national population ( 1 ). Over half of this population grapples with high morbidity rates, including prevalent conditions such as diabetes, chronic obstructive pulmonary disease (COPD), and hypertension ( 2 , 3 ). Notably, approximately 96 million older adults experience varying degrees of disabilities ( 4 ), and have significant need for medical services and nursing care ( 5 ), such as home visits for medication, health monitoring, healthcare education, and psychological counseling ( 6 , 7 ). The aging population is accompanied by a growing burden of chronic diseases, necessitating a more intensive and effective healthcare system ( 8 ). The majority of older adults prefer 'ageing in place,' aligning with the traditional Chinese value of 'filial piety' ( 9 , 10 ). Those with better self-reported health are more inclined to remain at home ( 11 ). In China, the primary foundation of geriatric care is family support, which is further complemented by community assistance and institutional care, as per the '9073' model: 90% family care, 7% community support, and 3% institutional care ( 12 ). However, this model becomes increasingly critical when older adults face difficulties in performing basic activities of daily living due to frailty ( 13 ). Surprisingly, less than 10% of older adults with different levels of care dependency and associated needs have received assistance within community and home settings, which highlights a significant gap in care provision ( 14 ). The insufficiency of the current geriatric care system, combined with limited geriatric teams and government funding, poses challenges in meeting the healthcare needs of older adults living in the community ( 15 ). To address these gaps, the Chinese government promotes the integration of medical services within communities, with the aim of improving care quality, enhancing accessibility, and establishing dedicated geriatric teams ( 15 , 16 ). The World Health Organisation (WHO) has proposed an integrated care model known as the PRISMA, which focuses on providing integrated care to older adults and frail individuals living in the community through a network of different providers. A key element of this model is the implementation of case management, with a dedicated case manager responsible for coordinating care for patients ( 17 ). Case managers, widely utilised in the United States and Europe in improving care delivery and cost-efficiency for older adults with complex needs. Additionally, they strive to meet the needs of various stakeholders, such as family members, healthcare professionals, informal caregivers, and other healthcare providers ( 18 – 20 ). To effectively make decisions and bridge the gap in patient demands, case managers consider alternatives and identify the best solution for patients through a step-by-step process ( 21 ) and enhance healthcare access with external support for community-dwelling older adults ( 22 , 23 ). In China, few studies have indicated that case management can reduce emergency attendance and hospital readmission rates among older adults, increase out patient satisfaction, and save healthcare costs ( 24 , 25 ). The roles and functions of case managers are outlined in Box 1. Box 1: The roles and functions of case managers ( 26 ) Main function Working scope Advocacy Advocates on behalf of patients, organizations, or specific programs. This may involve advocating for their rights and interests as well as addressing systemic issues that hinder their progress. Care coordination Networks or coordinates with patients, caregivers, and other stakeholders. Distributes information and facilitates care coordination to enhance the continuity and timeliness of care. Monitors and oversees the patient’s care pathway, acting as a coordinator for the care team and facilitating care transitions in collaboration with care providers. Assists in rehabilitation. Case monitoring and patient needs assessment Assists patients and caregivers in setting and achieving care-related goals. Organises, plans, and implements activities based on these goals and the care plan. Conducts comprehensive initial and ongoing patient needs assessments. Monitors, tracks, documents, and evaluates care, making modifications as needed through patient-centered care. Screens patients for long-term services. Community engagement Collaborates with individuals from various community groups to engage in collective activities, such as fundraising and knowledge dissemination. Education Educates patients and their care teams about treatment options, potential complications and available financial support. Offers health promotion and self-management education to empower patients and foster autonomy. Educates other professionals about treatments, financial support for patients, and the responsibilities of a case manager. Administration and research activities Organises information on behalf of patients and their caregivers to access financial support and assistance. Mobilises and evaluates the appropriate utilisation of resources across different settings. Participates in cost-effectiveness and quality analysis, as well as assists in other research activities. Psychosocial support Provides emotional and informational support to patients and their families. Offers grief counselling and crisis intervention. Builds and maintains relationships with patients, caregivers, and their care team Navigation of services Assists patients and their caregivers in navigating the healthcare system by connecting them to relevant services across various sectors and settings. Initiates referrals to appropriate services and resources to optimise patient outcomes. Reduction of barriers Minimises or eliminates actual or perceived barriers to timely services, programs, or treatments. The certification of healthcare case managers in mainland China, which has been implemented since 2005 currently lacks comprehensive regulation and a clear definition. This impedes the ability of case managers to effectively fulfil their roles and responsibilities. Additionally, limited job opportunities have hindered the widespread adoption of healthcare case management ( 27 ). Research on their impact is limited and mostly focused on hospitals ( 28 , 29 ). There is an absence of studies on integrated care for community-dwelling older adults, and a lack of effective communication among stakeholders, creating barriers to seamless service integration ( 7 ). This study aims to address the improvement of the healthcare system through the integration of tailored care solutions. Implementing an active health-oriented care model that utilises case managers has the potential to significantly improve healthcare services by efficiently coordinating care resources ( 14 ). We hypothesise that Chinese community-dwelling older adults will highly accept the PRISMA integrated care model and they will have high expectations for integrated care through case managers. Thus, it is crucial to identify the unmet healthcare needs of older adults and to understand their perceptions of the PRISMA model. Developing tools to measure their expectations is also essential in optimising healthcare models to better serve this demographic. Study objectives To address the research gaps and test the hypotheses, an exploratory sequential mixed methods study will be undertaken. The objectives of the study are formulated as follows: Investigate the unmet healthcare needs of Chinese community-dwelling older adults. Explore the acceptability of the PRISMA integrated care model among this demographic. Examine the realistic needs of integrated care through a case manager among community-dwelling older adults. Develop a comprehensive questionnaire to assess general and specific expectations of Chinese community-dwelling older adults regarding integrated care through case managers. Examine the levels of their expectations for integrated care. Determine the sociodemographic characteristics of older adults that are associated with different levels of expectations. Formulate an evidence-based integrated care model tailored to optimise healthcare delivery for Chinese community-dwelling older adults. Methods An exploratory sequential mixed methods approach will be employed to address the research inquiries. The study will consist of three phases conducted in sequence. Phase I will involve a qualitative study to explore qualitative evidence aligned with study objectives 1–3. Phase II will focus on the development and validation of a questionnaire to investigate study objective 4. Lastly, Phase III will consist of a quantitative study using a survey conducted in three selected cities representing the Middle, East, and West of China ( 30 ), to achieve study objectives 5–7. Data integration will be achieved through a data-building approach, where both quantitative and qualitative data will be combined in the final analysis stage to enhance the understanding of complex phenomena, examine hypotheses, and deepen the findings ( 31 ). The PRISMA model for integrated care The analysis will be guided by the PRISMA model (Fig. 1 ) ( 32 ) as the conceptual framework. This model is designed for healthcare systems that are universal and predominantly publicly funded. It can be implemented at the linkage level, where independent organisations, such as healthcare systems, social service organisations, and community agencies initiate protocols and programs to facilitate referrals or collaborations to meet patients’ needs. The PRISMA model is more commonly implemented at a coordination level, which involves the development of mechanisms to manage patients’ complex needs while each organisation maintains its own structure but agrees to cooperate. Coordination between institutions is at the core of the PRISMA model. A multidisciplinary team of practitioners, led by a case manager, evaluates patients’ needs and provides the necessary care. Access to all healthcare services is facilitated through a single entry point, managed by the manager. This model not only facilitates care delivery but also continuously monitors resources to ensure the effectiveness and efficacy of services. In China, the long-term care system, including community-based care for older adults, has been shaped by policies, government funding, consumer needs, and market forces ( 33 ). Day care and temporary services are provided and supervised by community centers, which are government agencies aimed at relieving the burdens of family caregivers by offering basic nursing care, house cleaning, rehabilitation and counselling services ( 34 ). It is believed that the PRISMA model is suitable for generalisation to the universal healthcare system in China and can guide the analysis of qualitative evidence as well as the structure design and subscales of a new questionnaire. Phase I: A qualitative study During Phase I, a qualitative case study will be conducted using a purposive sampling method to recruit participants ( 35 ). The study aims to investigate the unmet healthcare needs, the acceptability of the PRISMA integrated care model, and the realistic needs of integrated care through a case manager among Chinese community-dwelling older adults. The PRISMA model will be introduced to participants along with a semi-structured interview guide, including probe questions, in simplified Chinese. In the context of realistic healthcare needs, it will refer to the current Chinese healthcare landscape ( 36 ). Three trained investigators will conduct interviews in the field. Settings The study will be conducted in the community health centers in Wenzhou, Zhejiang province, China. Wenzhou has a significant ageing population consisting of 19.3% of the total population, and is transitioning towards a super-ageing society ( 37 ). Community health centers in China play a pivotal role in the ongoing healthcare reform ( 38 , 39 ) and provide essential medical treatment, prevention, rehabilitation, and long-term care services to local residents, particularly for the older adults. Participants will be selected from these centres based on their engagement with healthcare services ( 40 ). Eligible participants seeking healthcare within their communities will be identified and selected for recruitment. Participants Community-dwelling older adults aged 60 and above will be included. The purposive sampling method will be employed to recruit individuals. The inclusion criteria for eligible older adults are: 1) having at least one chronic condition, such as ischemic heart disease, stroke, COPD, or type 2 diabetes; 2) visiting hospitals or community healthcare centers more than three times a year for their chronic condition management. Exclusion criteria include unwillingness to participate or difficulty in communication due to linguistic challenges, cognitive impairments like dementia, or swallowing difficulties like dysphagia. The perspectives of adult children of eligible older adults, care administrators, and healthcare professionals within communities, including nurses, family doctors, and administrators of civil affairs, will be considered to provide a comprehensive insight into this topic. Sampling process Investigators will identify and approach potential participants from selected urban community healthcare centres. Participants will be informed about the study, the PRISMA model, and the interview process. Preferences for the interview method (face-to-face or online) will be discussed, and arrangements will be made accordingly. Participants will receive monetary incentives ranging from 50 to 100 CNY ( $ 7–14). Data collection Data will be collected through in-depth interviews and focus groups conducted either face-to-face or online via WeChat, a widely used communication app in China that is similar in functionality to Facebook. WeChat has a significant user base among older adults in China, covering approximately 82% ( 41 ). Focus groups will consist of up to four participants. Participants will be required to sign a consent form, and the PRISMA model and the role of case managers will be explained using clear and simple language. During interviews, a semi-structured interview guide with probes will be used to elicit detailed responses. Interviews will be recorded in either video or audio format. A pilot interview with 2–3 participants will be conducted before the onsite investigation to refine the interview questions. Sociodemographic characteristics such as age, education, income, and the number and types of chronic conditions, will be collected. Additionally, the Chinese version of the Barthel Scale/Index (BI) will be used to assess the older adults’ levels of Activities of Daily Living (ADL). A total of 30 participants will be recruited, and the final sample size will be determined based on data saturation. The sample of open-ended questions and probes can be found in supplement file 1. Qualitative data analysis plan Raw data will be managed using NVIVO 11 or ATLAS.ti8. Trained investigators will transcribe the interviews verbatim, and an additional investigator will conduct a data audit. Thematic and coding analysis will be conducted using both inductive and deductive approaches, guided by the PRISMA model. The data will be analysed using the framework method, which consists of six steps: ( 1 ) reviewing transcripts and noting initial ideas about themes; ( 2 ) developing a coding system based on the transcripts; ( 3 ) conducting weekly team meetings to identify recurring themes; ( 4 ) comparing themes across participants through constant comparative analysis; ( 5 ) defining and naming themes; ( 6 ) compiling a written report of the findings. Phase II: Questionnaire development and validation The aim of Phase II is to develop and validate a questionnaire based on the PRISMA model and Phase I outcomes. This tool will be used to assess the levels of expectations for integrated care through case managers among older adults, examining both general and specific expectations, as well as their sociodemographic characteristics correlates. Questionnaire design and measurement The questionnaire will be divided into two sections: 1) sociodemographic characteristics, including age, income, number and type of chronic conditions. The BI Scale for ADL will be assessed using a combined tool; 2) items of expectations related to integrated care through case managers. This section is informed by qualitative outcomes from Phase I, with variables derived from coded data and scales based on identified themes. Questionnaire items are constructed using direct quotations from the qualitative study, aligning with the PRISMA model and emerging codes from Phase I. To quantify the level of expectations, a 5-point Likert scale will be employed, allowing for categorisation of responses into three groups: low, medium, and high expectations. This categorisation can be applied at both the item level and construct level, based on the scale's properties. The final questionnaire is anticipated to consist of approximately 50 items in the expectations section, with a completion time of around 30 minutes. Questionnaire validity and reliability The face and content validity of the items in the questionnaire will be assessed by a panel of at least six experts, including nurses, geriatricians, statisticians, healthcare case managers, social workers, and older adults. The feedback provided by the panel members will be used to calculate the content validity index (CVI) for each item included in the questionnaire ( 42 ). The relevance, comprehensibility, and comprehensiveness of the items will be evaluated using the COnsensus-based Standards for the selection of health status Measurement INstruments check list ( 43 ). To assess structural validity, a pilot study will be conducted. The structural validity of the questionnaire will be assessed through a pilot study, employing Exploratory Factor Analysis (EFA) to examine the underlying factor structure. Factors with an eigenvalue greater than 1 will be retained, while items with factor loadings below 0.40 or significant cross-loadings will be excluded ( 44 ). Structural Equation Modeling (SEM) will be used to evaluate the model fit, ensuring that the data supports the hypothesized factor structure. Internal consistency of the questionnaire will be evaluated using Cronbach's alpha, with a threshold of 0.70 or higher indicating acceptable reliability ( 45 ). Additionally, the reliability of the questionnaire will be assessed using intra-class coefficients (ICC) to determine intra-rater test-retest reliability. A random sample of at least 50 participants will be selected to complete the questionnaire twice, with a one-month interval between administrations ( 43 ). An ICC value between 0.50 and 0.75 will be interpreted as moderate reliability, while a value of 0.75 or higher will be considered indicative of good reliability ( 46 ). Phase III: A quantitative study through a survey In Phase III, a survey will be conducted to examine the expectations of integrated care through case managers among Chinese community-dwelling older adults and their associated sociodemographic characteristics. The survey will use a validated questionnaire that has been developed in Phase II. The questionnaire will be provided in Chinese either through a web-based platforms such as wjx.cn or as printed hard copies. Online participants will need to provide their Informed Consent Form by clicking a response button, while onsite participants will be required to provide a signature. Additionally, a data integration approach will be applied to combine the quantitative and qualitative data from Phase I and Phase III. This approach aims to enhance the understanding of complex phenomena, examine hypotheses, and deepen the findings. Based on the outcomes, an evidence-based framework will be formulated to optimise healthcare delivery for Chinese community-dwelling older adults. Setting In China, there is an uneven distribution of population and regional economic development, with a gradually declining trend from east to west ( 47 ). The survey will be conducted in three major cities: Wenzhou, Taiyuan, and Hainan. Wenzhou, located almost at the center of China's eastern coast, has a significant aging population. Older adults in Wenzhou prefer to reside in their homes and communities and receive integrated healthcare services align with Chinese culture values ( 48 ). Wenzhou is known as a pioneer in China's private economy, with a thriving small and medium-sized enterprise sector. It is considered one of the economically developed coastal regions in the east of China ( 49 ). Taiyuan, the capital city of Shanxi province, represents the west of China. The average income in this area is slightly below the national average ( 50 ). The number of older adults aged 60 and above in Taiyuan has exceeded 21.9% of the total population, indicating that it has entered a super-ageing society ( 51 ). Hainan (island), China's southernmost province, is also experiencing rapid ageing. The number of local older adults aged 60 and above in Hainan has reached 1.46 million, accounting for 15.5% of the total local population ( 52 ). Due to its prosperous economy and pleasant living environment, Hainan has become a highly sought-after location for older individuals, particularly during winter migration from 27 different provinces across China ( 53 , 54 ). The samples from Hainan are more representative of a large ageing population. Participants and sample size estimation In accordance with the sample in the qualitative study, the quantitative study will recruit older adults who meet the following criteria: 1) aged ≥ 60, 2) living independently in the community, 3) having at least one chronic condition, and 4) visiting a hospital or clinic more than three times a year to manage their chronic diseases. Individuals who are unwilling to participate, have language difficulties, or cognitive impairments will be excluded. Based on an expected 18.8% level of expectations of chronic disease management services among Chinese older adults ( 55 ), a 95% confidence level with a two-sided and 5% margin of error, the minimum required sample size was 235. However, a target sample size of 354 (118 in each city) is set with a response rate of approximately 80% for non-response and incompletion rates. Sampling process A stratified random sampling method will be used to ensure that the sample accurately represents the diversity of older adults. Six community medical centres will be randomly selected from three cities, with two centers chosen from each city. Initially, six enumerators (two in each city) will propose four communities and specialised geriatric hospitals in each city where the ageing population exceeds 21% of the community's total population. Two of these communities will then be randomly chosen to ensure an unbiased representation. Recruitment will be carried out through posters, flyers, announcements in medical centers, and various outreach methods such as online platforms and community events to maximise participation. Participants will be requested to provide demographic information, which will be used to stratify the sample based on age and presence of chronic diseases prior to randomly selecting participants within each stratum. This approach ensures that the sample reflects the diversity of older adults across different community medical centers and cities. Data collection process Onsite investigators, comprising of at least one investigator and one research assistant in each city, will be responsible for overseeing the data collection process. At these selected sites, investigators will screen older adults based on the inclusion criteria to determine their eligibility. Those who meet the criteria will then be approached and provided with detailed information of the study. Simultaneously, participants will be informed about the study's objectives and asked to provide their consent. Informed consent will be obtained through either signed forms for onsite participants or electronic consent for online participants. To facilitate accurate data collection, participants will have the option to provide their telephone numbers, which will enhance the study's credibility and support convenient recruitment for intra-rater test-retest. Collected data will be entered into a database and undergo a double-checking process by investigators and research assistants to ensure accuracy and completeness. Measurement At the beginning of the questionnaire, a description of the modified PRISMA model in simple Chinese language will be provided to explain the concept of integrated care through a single entry point by a case manager. Participants will be asked to repeat the PRISMA model to confirm their understanding of the fundamental concept. Sociodemographic characteristics Specific age and hospitalisation within the previous year will be collected as numerical variables. Other variables will be categorized as descriptive variables. For example, gender (male or female), health status (healthy, living with one chronic disease, and living with two or more chronic diseases), monthly income ( \(\:\) 749 USD), education (no formal education, elementary school, middle school, high school, bachelor’s degrees or above), occupation (employed, unemployed, retired), insurance (No insurance, UEBMI=Urban Employee Basic Medical Insurance, URBMI=Urban Resident Basic Medical Insurance, and NRCMI=New Rural Cooperative Medical Insurance), number of children (no child, 1 child, 2 children, and 3 or more children), and living arrangements (alone, with a partner, with a child or children, with a partner and children, and living with others such as a housemaid). Barthel Index (BI) This section will include ten items to aid in evaluating and categorising the level of ADL among participants. The BI scale was developed to assess a patient’s self-care abilities in ten areas, including control of bowel and bladder. The patient is scored ranging from 0 to 15 points in different categories, based on their need for assistance, such as in feeding, bathing, dressing, and walking ( 56 ). The Chinese version of the BI Scale has been validated and extensively implemented in various clinical assessment settings ( 57 , 58 ). The BI is conventionally divided into four levels of scores using the following divisions: 100 − 91 (complete independence), 90 − 61 (slight level of dependence), 60 − 21 (moderate dependence), and ≤ 20 (severe dependence) ( 59 ). Expectation section The variables in the final version of the questionnaire will be categorised as individual items and groups within the construct to measure participants’ overall and specific expectations of integrated care. A 5-point Likert scale ranging from 1 to 5 will be used to indicate expectations from low to high. Data analysis for the quantitative study The IBM Statistical Package for the Social Sciences (SPSS 26) will be utilised to input and analyse quantitative data. Data from online questionnaires will be automatically transferred to SPSS, while data from hard-copy questionnaires will be manually entered into the dataset. The mean expectation scores will be categorised into tertiles, representing the lowest, middle, and highest levels of expectations. Chi-square tests will be conducted to explore the relationship between sociodemographic characteristics and the different expectation categories for integrated care. A significance level of p < 0.05, with a 95% confidence interval, will be used to determine statistical significance. Multiple logistic regression models will be employed to analyse the association of independent variables with the levels of expectation, using the lowest tertile of expectation as the reference group. Independent variables with a p -value < 0.20 from univariable regression analysis will be considered for inclusion in the final multiple regression model. The presence of multicollinearity among independent variables will be evaluated using a tolerance threshold of < 0.4 or a Variance Inflation Factor (VIF) ≥ 2.5. The adequacy of model fitting will be evaluated, and Q-Q plots for normality, residual plots for linearity and homogeneity assumptions will be examined. Skewness and kurtosis statistics will be utilised to assess the statistical assumptions of survey item responses. A moderate normality threshold of 2.0 and 7.0 will be applied for skewness and kurtosis, respectively, in the assessment of multivariate normality ( 60 ). Discussion This study aims to develop and evaluate an evidence-based integrated care model tailored to the specific needs of Chinese community-dwelling older adults with complex healthcare needs, with a focus on chronic diseases, multimorbidity, and physical impairments ( 61 ). By incorporating elements from the PRISMA model and considering the specific expectations and conditions of the ageing population in China, this study strives to promote integrated care through a centralised point of access managed by a case manager. This approach addresses significant gaps in current healthcare provision and aims to improve the quality, accessibility, and efficiency of services, thereby enhancing care for China's ageing population. The utilisation of healthcare case management services has shown notable benefits for the healthcare of older adults living in the community, particularly those who are frail ( 23 ). This approach to healthcare coordination ensures that older adults with multiple health conditions receive appropriate care without any gaps or duplications, as care is coordinated across multiple healthcare providers ( 62 , 63 ). By identifying and managing health conditions in their early stages, case managers can help mitigate the risk of complications and hospitalisations, resulting in improved health outcomes ( 64 ). The personalised support and care delivered by case managers can also enhance patient satisfaction with their healthcare experience ( 65 , 66 ). Additionally, this approach can contribute to disease detection, thereby preventing costly hospitalisations and making care more cost-effective ( 67 , 68 ). Healthcare case management services can also facilitate access to resources and services that enhance the quality of life for older adults, such as transportation, social activities, and home health services ( 65 , 69 ). Furthermore, support is provided to family members and informal caregivers, assisting them in managing the physical, emotional, and financial demands associated with caring for older adults ( 70 , 71 ). Extensive research has been conducted on integrated care models for older adults, particularly in Western countries where these models have been implemented to varying degrees of success. For example, the PRISMA model has been widely studied in Canada and has demonstrated improvements in continuity of care, reduced hospitalisations, and improved patient satisfaction ( 72 ). Similarly, other integrated care models, such as the Chronic Care Model (CCM) in Europe ( 73 ) and the Kaiser Permanente model in America have shown positive outcomes in managing chronic diseases among older adults ( 74 ). However, the PRISMA model is better suited to the Chinese healthcare system. In the context of China, the existing healthcare system is fragmented and ill-prepared to provide a comprehansive continuum of care for chronic diseases. Therefore, there is a pressing need to develop integrated and efficient care, particularly for older adults ( 75 ). China's regional healthcare system, led by the government, integrates large and medium-sized hospitals with primary healthcare institutions to form a collaborative medical community. This facilitates resource sharing, access to advanced facilities, and expert guidance, enabling the delivery of safe, effective, and continuous integrated care, particularly for older adults with multiple comorbidities ( 76 ). Despite active exploration by experts to identify integrated care models suitable for China, most studies primarily rely on literature reviews. Fewer studies employ qualitative and quantitative research to validate these models among elderly populations and stakeholders ( 77 ). This study significantly contributes to the field of geriatric care by proposing and evaluating an integrated care model tailored to the specific needs of Chinese older adults. By employing a mixed-methods approach that combines qualitative and quantitative data, the comprehensive understanding of the expectations and needs of older adults towards integrated care will be enhanced. The findings of this study have the potential to inform policy decisions, guide the implementation of integrated care models, and ultimately improve health outcomes and quality of life for Chinese older adults. Declarations Ethics approval and consent to participate Ethical approval for this study has been obtained from Zhejiang Dongfang Polytechnic, China (Approval No. GZSQ202408120010). Participants will be provided with a respondent Information Sheet and Informed Consent Form, which they will be required to sign before participating in interviews and surveys. Consent for publication Not applicable Availability of data and materials The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request. Competing interests The authors declare that they have no competing interests. Funding This study is part of a project financially supported by the China Association of Social Workers (CASW) and Zhejiang Dongfang Polytechnic, China. As a public interest social research project, the funders have no role in the study design, execution, analysis, interpretation of data, or the decision to submit results. Authors' contributions All authors contributed to writing the manuscript. ZYY initiated and contributed to the design of the study. In the ongoing process, ZYY will be in charge of implementing the study, while TYH will translate interview transcripts into English and audit the raw data. ZH will assist in conducting on-site data collection. All authors have read and approved the final manuscript. Acknowledgements Not applicable Authors' information ZYY is currently leading the development of academic disciplines for smart ageing at the School of Smart Health and Wellness, Health Medical College, Zhejiang Dongfang Polytechnic, China. This interdisciplinary field, situated at the intersection of health, engineering, and social sciences, focuses on enhancing China's public health system and promoting healthy ageing. TYH is affiliated with Jiangxi Science and Technology Normal University, China. His research interests include education for older adults and cross-cultural social services. ZH is the Director of the Health Management Department at the School of Smart Health and Wellness, Health Medical College, Zhejiang Dongfang Polytechnic, China. Her research interests include traditional Chinese medicine, geriatric health management, and community-based health planning and services. References Xinhua. 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Globalization health. 2019;15(1):1–21. Shi J, Chen N, Liu N, Yang Y, Yu D, Jin H, et al. Options for care of elderly inpatients with chronic diseases: analysis of distribution and factors influencing use of care in Shanghai, China. Front Public Health. 2021;9:631189. Lu H, Kandilov IT. Does mobile internet use affect the subjective well-being of older Chinese adults? An instrumental variable quantile analysis. J Happiness Stud. 2021:1–20. Yusoff MSB. ABC of content validation and content validity index calculation. Resource. 2019;11(2):49–54. Mokkink LB, Terwee CB, Knol DL, Stratford PW, Alonso J, Patrick DL, et al. The COSMIN checklist for evaluating the methodological quality of studies on measurement properties: a clarification of its content. BMC Med Res Methodol. 2010;10(1):1–8. Samuels P. Advice on exploratory factor analysis. 2017. Taber KS. The use of Cronbach’s alpha when developing and reporting research instruments in science education. Res Sci Educ. 2018;48(6):1273–96. Koo TK, Li MY. A guideline of selecting and reporting intraclass correlation coefficients for reliability research. J Chiropr Med. 2016;15(2):155–63. Wang J, Zhai T, Lin Y, Kong X, He T. Spatial imbalance and changes in supply and demand of ecosystem services in China. Sci Total Environ. 2019;657:781–91. Liu Y, Li X, Lin Y. A Care Needs Assessment of Elderlies in Empty Nest Families: The Case of Wenzhou, China. Int J Educ Humanit. 2022;4(3):91–101. Yifan Z, Yusof RB. An Evaluation of Business Environmental Index System: Future Direction for SMEs in China. Global Bus Manage Res. 2022;14. Cao W, Guo C, Ping W, Tan Z, Guo Y, Zheng J. A community-based study of quality of life and depression among older adults. Int J Environ Res Public Health. 2016;13(7):693. MHC. Taiyuan's 11 Measures to Build a Health and Wellness Service System: Taiyuan Municipal Health Commission. 2024 [ https://wjw.taiyuan.gov.cn/wjyw/20240408/30116692.html Hainan. Hainan Provincial Working Committee on Ageing Report on Information on the Elderly Population and the Development Status of Ageing Health in Hainan Province (2019) (CN). Xinlang2019. Li J. The New Role of the Migratory Bird Elderly Economic Senator News Paper2018 [ http://dz.jjckb.cn/www/pages/webpage2009/html/2018-03/08/content_41512.htm Wang Z, Xu N, Wei W, Zhao N. Social inequality among elderly individuals caused by climate change: Evidence from the migratory elderly of mainland China. J Environ Manage. 2020;272:111079. Huang Z, Liu Q, Meng H, Liu D, Dobbs D, Hyer K et al. Factors associated with willingness to enter long-term care facilities among older adults in Chengdu. China. 2018;13(8). Mahoney FI. Functional evaluation: the Barthel index. Maryland State Med J. 1965;14(2):61–5. Leung SO, Chan CC, Shah S. Development of a Chinese version of the Modified Barthel Index—validity and reliability. Clin Rehabil. 2007;21(10):912–22. Min Y, WU Y, Yan T. Validity and reliability of the simplified Chinese version of modified Barthel index for Chinese stroke patients. Chin J Phys Med Rehabilitation. 2008:185–8. Strini V, Piazzetta N, Gallo A, Schiavolin R. Barthel Index: creation and validation of two cut-offs using the BRASS Index. Acta Bio Medica: Atenei Parmensis. 2020;91(Suppl 2):19. Curran PJ, West SG, Finch JF. The robustness of test statistics to nonnormality and specification error in confirmatory factor analysis. Psychol Methods. 1996;1(1):16. Li C, Zhou R, Yao N, Cornwell T, Wang S. Health care utilization and unmet needs in Chinese older adults with multimorbidity and functional impairment. J Am Med Dir Assoc. 2020;21(6):806–10. Manderson B, Mcmurray J, Piraino E, Stolee P. Navigation roles support chronically ill older adults through healthcare transitions: a systematic review of the literature. Health Soc Care Commun. 2012;20(2):113–27. Mathew J, Patel HP. Integrated care for older adults living with frailty. Clin Integr Care. 2021;9:100078. Prince M, Comas-Herrera A, Knapp M, Guerchet M, Karagiannidou M. World Alzheimer report 2016: improving healthcare for people living with dementia: coverage, quality and costs now and in the future. 2016. Reilly S, Miranda-Castillo C, Malouf R, Hoe J, Toot S, Challis D et al. Case management approaches to home support for people with dementia. Cochrane Database Syst Reviews. 2015(1). Threapleton DE, Chung RY, Wong SY, Wong E, Chau P, Woo J, et al. Integrated care for older populations and its implementation facilitators and barriers: A rapid scoping review. Int J Qual Health Care. 2017;29(3):327–34. Joo J, Liu M. Case management effectiveness in reducing hospital use: a systematic review. Int Nurs Rev. 2017;64(2):296–308. Chodosh J, Colaiaco BA, Connor KI, Cope DW, Liu H, Ganz DA, et al. Dementia care management in an underserved community: the comparative effectiveness of two different approaches. J Aging Health. 2015;27(5):864–93. Batchelor F, Hwang K, Haralambous B, Fearn M, Mackell P, Nolte L, et al. Facilitators and barriers to advance care planning implementation in Australian aged care settings: a systematic review and thematic analysis. Australas J Ageing. 2019;38(3):173–81. Berthelsen CB, Kristensson J. The content, dissemination and effects of case management interventions for informal caregivers of older adults: a systematic review. Int J Nurs Stud. 2015;52(5):988–1002. Smith R, Martin A, Wright T, Hulbert S, Hatzidimitriadou E. Integrated dementia care: A qualitative evidence synthesis of the experiences of people living with dementia, informal carers and healthcare professionals. Arch Gerontol Geriatr. 2021;97:104471. Hébert R, Raîche M, Dubois M-F, Gueye NDR, Dubuc N, Tousignant M, et al. Impact of PRISMA, a coordination-type integrated service delivery system for frail older people in Quebec (Canada): A quasi-experimental study. Journals Gerontol Ser B: Psychol Sci Social Sci. 2010;65(1):107–18. Brettel JH, Manuwald U, Hornstein H, Kugler J, Rothe U. Chronic-Care‐Management Programs for Multimorbid Patients with Diabetes in Europe: A Scoping Review with the Aim to Identify the Best Practice. J Diabetes Res. 2021;2021(1):6657718. Rompen L, de Vries NM, Munneke M, Neff C, Sachs T, Cedrone S, et al. Introduction of network-based healthcare at Kaiser Permanente. J Parkinson's disease. 2020;10(1):207–12. Organization WH. China country assessment report on ageing and health. 2015. ZHOU X. Construction of an Integrated Management Model for Geriatric Comorbidities under Medical Association Based on PDSA Theory. Chin Gen Pract. 2024;27(02):192. Li W, Jing Q, Shang Q, Ouyang X, Sun S, Lv N et al. CiteSpace-based Integrated Care for the Elderly Research Hotspot and Trend Analysis (CN). Chin Nurs Res. 2022;36(17). Additional Declarations No competing interests reported. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4901154","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Study protocol","associatedPublications":[],"authors":[{"id":348864948,"identity":"70149249-efcc-4074-abda-fc58e2fbcee8","order_by":0,"name":"Yuanyuan Zhao","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA0klEQVRIiWNgGAWjYBACAwbmBiB1gIFB/vHBB0RqYYRqYUhLNiBVS46ZBFFazNkbGx8X/Lkjz89wLK3iTRmDPL/YAfxaLHsONhvP4HlmOLOx+djNOecYDGfOTiDgsBuJbdI8EocZNxxmS7vN28aQYHCbkJb7D9t/8xgctt9wjMesmDgtNxjbmHkSDiduOMNjxkycljOJzdI8Bw4nz5zBliw555wEEX45fvjgZ54/h237JZgPfnhTZiPPL01ACyrgYSMualC0kKpjFIyCUTAKRgIAAM7IR3CjVJqUAAAAAElFTkSuQmCC","orcid":"","institution":"Zhejiang Dongfang Polytechnic, China","correspondingAuthor":true,"prefix":"","firstName":"Yuanyuan","middleName":"","lastName":"Zhao","suffix":""},{"id":348864949,"identity":"3548c364-2a9b-4ab9-b8ad-9a7cf8797d2a","order_by":1,"name":"Yuehua Tu","email":"","orcid":"","institution":"Jiangxi Science and Technology Normal University","correspondingAuthor":false,"prefix":"","firstName":"Yuehua","middleName":"","lastName":"Tu","suffix":""},{"id":348864950,"identity":"c89fc17e-0a17-42e9-831d-6ae3389fbd75","order_by":2,"name":"Hua Zhu","email":"","orcid":"","institution":"Zhejiang Dongfang Polytechnic, China","correspondingAuthor":false,"prefix":"","firstName":"Hua","middleName":"","lastName":"Zhu","suffix":""}],"badges":[],"createdAt":"2024-08-12 14:13:57","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4901154/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4901154/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":66674875,"identity":"3d713777-6de6-4524-809c-d6be48f193c8","added_by":"auto","created_at":"2024-10-15 11:02:35","extension":"jpeg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":105060,"visible":true,"origin":"","legend":"\u003cp\u003eThe PRISMA model of integrated care\u003c/p\u003e","description":"","filename":"floatimage1.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-4901154/v1/6c0ef817186e4e2b8154559c.jpeg"},{"id":71264231,"identity":"4c7da6ce-b307-43e2-a730-4ca944a84260","added_by":"auto","created_at":"2024-12-12 17:08:44","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":469686,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4901154/v1/17ff2ae7-5a9e-4ec9-8e06-2daf5e8d4da5.pdf"},{"id":66674873,"identity":"322079f4-3c2c-4f38-8c2e-3d6f3e7ba1c7","added_by":"auto","created_at":"2024-10-15 11:02:35","extension":"docx","order_by":3,"title":"","display":"","copyAsset":false,"role":"supplement","size":14632,"visible":true,"origin":"","legend":"","description":"","filename":"Supplementfile1openendedquestionsandprobes.docx","url":"https://assets-eu.researchsquare.com/files/rs-4901154/v1/e2feddcc6b42b4ad39a21902.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Chinese Community-dwelling Older Adults’ Expectations regarding the Delivery of Integrated Care through Case Managers: A Mixed Methods Study Protocol","fulltext":[{"header":"Background","content":"\u003cp\u003eThe National Bureau of Statistics has revealed that the ageing population in China, aged 60 and above, has exceeded 290\u0026nbsp;million by the end of 2023, accounting for approximately 21.1% of the national population (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). Over half of this population grapples with high morbidity rates, including prevalent conditions such as diabetes, chronic obstructive pulmonary disease (COPD), and hypertension (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). Notably, approximately 96\u0026nbsp;million older adults experience varying degrees of disabilities (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e), and have significant need for medical services and nursing care (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e), such as home visits for medication, health monitoring, healthcare education, and psychological counseling (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e). The aging population is accompanied by a growing burden of chronic diseases, necessitating a more intensive and effective healthcare system (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe majority of older adults prefer 'ageing in place,' aligning with the traditional Chinese value of 'filial piety' (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e). Those with better self-reported health are more inclined to remain at home (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e). In China, the primary foundation of geriatric care is family support, which is further complemented by community assistance and institutional care, as per the '9073' model: 90% family care, 7% community support, and 3% institutional care (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e). However, this model becomes increasingly critical when older adults face difficulties in performing basic activities of daily living due to frailty (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e). Surprisingly, less than 10% of older adults with different levels of care dependency and associated needs have received assistance within community and home settings, which highlights a significant gap in care provision (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e). The insufficiency of the current geriatric care system, combined with limited geriatric teams and government funding, poses challenges in meeting the healthcare needs of older adults living in the community (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e). To address these gaps, the Chinese government promotes the integration of medical services within communities, with the aim of improving care quality, enhancing accessibility, and establishing dedicated geriatric teams (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe World Health Organisation (WHO) has proposed an integrated care model known as the PRISMA, which focuses on providing integrated care to older adults and frail individuals living in the community through a network of different providers. A key element of this model is the implementation of case management, with a dedicated case manager responsible for coordinating care for patients (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e). Case managers, widely utilised in the United States and Europe in improving care delivery and cost-efficiency for older adults with complex needs. Additionally, they strive to meet the needs of various stakeholders, such as family members, healthcare professionals, informal caregivers, and other healthcare providers (\u003cspan additionalcitationids=\"CR19\" citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e). To effectively make decisions and bridge the gap in patient demands, case managers consider alternatives and identify the best solution for patients through a step-by-step process (\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e) and enhance healthcare access with external support for community-dwelling older adults (\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e). In China, few studies have indicated that case management can reduce emergency attendance and hospital readmission rates among older adults, increase out patient satisfaction, and save healthcare costs (\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e). The roles and functions of case managers are outlined in Box 1.\u003c/p\u003e \u003cp\u003eBox 1: The roles and functions of case managers (\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e)\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"No\" id=\"Taba\" border=\"1\"\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMain function\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eWorking scope\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAdvocacy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAdvocates on behalf of patients, organizations, or specific programs. This may involve advocating for their rights and interests as well as addressing systemic issues that hinder their progress.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCare coordination\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNetworks or coordinates with patients, caregivers, and other stakeholders. Distributes information and facilitates care coordination to enhance the continuity and timeliness of care. Monitors and oversees the patient\u0026rsquo;s care pathway, acting as a coordinator for the care team and facilitating care transitions in collaboration with care providers. Assists in rehabilitation.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCase monitoring and patient needs assessment\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAssists patients and caregivers in setting and achieving care-related goals. Organises, plans, and implements activities based on these goals and the care plan. Conducts comprehensive initial and ongoing patient needs assessments. Monitors, tracks, documents, and evaluates care, making modifications as needed through patient-centered care. Screens patients for long-term services.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCommunity engagement\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCollaborates with individuals from various community groups to engage in collective activities, such as fundraising and knowledge dissemination.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEducation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eEducates patients and their care teams about treatment options, potential complications and available financial support. Offers health promotion and self-management education to empower patients and foster autonomy. Educates other professionals about treatments, financial support for patients, and the responsibilities of a case manager.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAdministration and research activities\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOrganises information on behalf of patients and their caregivers to access financial support and assistance. Mobilises and evaluates the appropriate utilisation of resources across different settings. Participates in cost-effectiveness and quality analysis, as well as assists in other research activities.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePsychosocial support\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eProvides emotional and informational support to patients and their families. Offers grief counselling and crisis intervention. Builds and maintains relationships with patients, caregivers, and their care team\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNavigation of services\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAssists patients and their caregivers in navigating the healthcare system by connecting them to relevant services across various sectors and settings. Initiates referrals to appropriate services and resources to optimise patient outcomes.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eReduction of barriers\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMinimises or eliminates actual or perceived barriers to timely services, programs, or treatments.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eThe certification of healthcare case managers in mainland China, which has been implemented since 2005 currently lacks comprehensive regulation and a clear definition. This impedes the ability of case managers to effectively fulfil their roles and responsibilities. Additionally, limited job opportunities have hindered the widespread adoption of healthcare case management (\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e). Research on their impact is limited and mostly focused on hospitals (\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e). There is an absence of studies on integrated care for community-dwelling older adults, and a lack of effective communication among stakeholders, creating barriers to seamless service integration (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e This study aims to address the improvement of the healthcare system through the integration of tailored care solutions. Implementing an active health-oriented care model that utilises case managers has the potential to significantly improve healthcare services by efficiently coordinating care resources (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e). We hypothesise that Chinese community-dwelling older adults will highly accept the PRISMA integrated care model and they will have high expectations for integrated care through case managers. Thus, it is crucial to identify the unmet healthcare needs of older adults and to understand their perceptions of the PRISMA model. Developing tools to measure their expectations is also essential in optimising healthcare models to better serve this demographic.\u003c/p\u003e \u003cp\u003eStudy objectives\u003c/p\u003e \u003cp\u003eTo address the research gaps and test the hypotheses, an exploratory sequential mixed methods study will be undertaken. The objectives of the study are formulated as follows:\u003c/p\u003e \u003cp\u003e \u003col\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eInvestigate the unmet healthcare needs of Chinese community-dwelling older adults.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eExplore the acceptability of the PRISMA integrated care model among this demographic.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eExamine the realistic needs of integrated care through a case manager among community-dwelling older adults.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eDevelop a comprehensive questionnaire to assess general and specific expectations of Chinese community-dwelling older adults regarding integrated care through case managers.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eExamine the levels of their expectations for integrated care.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eDetermine the sociodemographic characteristics of older adults that are associated with different levels of expectations.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eFormulate an evidence-based integrated care model tailored to optimise healthcare delivery for Chinese community-dwelling older adults.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003c/ol\u003e \u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eAn exploratory sequential mixed methods approach will be employed to address the research inquiries. The study will consist of three phases conducted in sequence. Phase I will involve a qualitative study to explore qualitative evidence aligned with study objectives 1\u0026ndash;3. Phase II will focus on the development and validation of a questionnaire to investigate study objective 4. Lastly, Phase III will consist of a quantitative study using a survey conducted in three selected cities representing the Middle, East, and West of China (\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e), to achieve study objectives 5\u0026ndash;7. Data integration will be achieved through a data-building approach, where both quantitative and qualitative data will be combined in the final analysis stage to enhance the understanding of complex phenomena, examine hypotheses, and deepen the findings (\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe PRISMA model for integrated care\u003c/p\u003e \u003cp\u003eThe analysis will be guided by the PRISMA model (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e) (\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e) as the conceptual framework. This model is designed for healthcare systems that are universal and predominantly publicly funded. It can be implemented at the linkage level, where independent organisations, such as healthcare systems, social service organisations, and community agencies initiate protocols and programs to facilitate referrals or collaborations to meet patients\u0026rsquo; needs. The PRISMA model is more commonly implemented at a coordination level, which involves the development of mechanisms to manage patients\u0026rsquo; complex needs while each organisation maintains its own structure but agrees to cooperate. Coordination between institutions is at the core of the PRISMA model. A multidisciplinary team of practitioners, led by a case manager, evaluates patients\u0026rsquo; needs and provides the necessary care. Access to all healthcare services is facilitated through a single entry point, managed by the manager. This model not only facilitates care delivery but also continuously monitors resources to ensure the effectiveness and efficacy of services. In China, the long-term care system, including community-based care for older adults, has been shaped by policies, government funding, consumer needs, and market forces (\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e). Day care and temporary services are provided and supervised by community centers, which are government agencies aimed at relieving the burdens of family caregivers by offering basic nursing care, house cleaning, rehabilitation and counselling services (\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e). It is believed that the PRISMA model is suitable for generalisation to the universal healthcare system in China and can guide the analysis of qualitative evidence as well as the structure design and subscales of a new questionnaire.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003ePhase I: A qualitative study\u003c/p\u003e \u003cp\u003eDuring Phase I, a qualitative case study will be conducted using a purposive sampling method to recruit participants (\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e). The study aims to investigate the unmet healthcare needs, the acceptability of the PRISMA integrated care model, and the realistic needs of integrated care through a case manager among Chinese community-dwelling older adults. The PRISMA model will be introduced to participants along with a semi-structured interview guide, including probe questions, in simplified Chinese. In the context of realistic healthcare needs, it will refer to the current Chinese healthcare landscape (\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e). Three trained investigators will conduct interviews in the field.\u003c/p\u003e \u003cp\u003eSettings\u003c/p\u003e \u003cp\u003eThe study will be conducted in the community health centers in Wenzhou, Zhejiang province, China. Wenzhou has a significant ageing population consisting of 19.3% of the total population, and is transitioning towards a super-ageing society (\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e). Community health centers in China play a pivotal role in the ongoing healthcare reform (\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e, \u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e) and provide essential medical treatment, prevention, rehabilitation, and long-term care services to local residents, particularly for the older adults. Participants will be selected from these centres based on their engagement with healthcare services (\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e). Eligible participants seeking healthcare within their communities will be identified and selected for recruitment.\u003c/p\u003e \u003cp\u003eParticipants\u003c/p\u003e \u003cp\u003eCommunity-dwelling older adults aged 60 and above will be included. The purposive sampling method will be employed to recruit individuals. The inclusion criteria for eligible older adults are: 1) having at least one chronic condition, such as ischemic heart disease, stroke, COPD, or type 2 diabetes; 2) visiting hospitals or community healthcare centers more than three times a year for their chronic condition management. Exclusion criteria include unwillingness to participate or difficulty in communication due to linguistic challenges, cognitive impairments like dementia, or swallowing difficulties like dysphagia. The perspectives of adult children of eligible older adults, care administrators, and healthcare professionals within communities, including nurses, family doctors, and administrators of civil affairs, will be considered to provide a comprehensive insight into this topic.\u003c/p\u003e \u003cp\u003eSampling process\u003c/p\u003e \u003cp\u003eInvestigators will identify and approach potential participants from selected urban community healthcare centres. Participants will be informed about the study, the PRISMA model, and the interview process. Preferences for the interview method (face-to-face or online) will be discussed, and arrangements will be made accordingly. Participants will receive monetary incentives ranging from 50 to 100 CNY (\u003cspan\u003e$\u003c/span\u003e7\u0026ndash;14).\u003c/p\u003e \u003cp\u003eData collection\u003c/p\u003e \u003cp\u003eData will be collected through in-depth interviews and focus groups conducted either face-to-face or online via WeChat, a widely used communication app in China that is similar in functionality to Facebook. WeChat has a significant user base among older adults in China, covering approximately 82% (\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e). Focus groups will consist of up to four participants. Participants will be required to sign a consent form, and the PRISMA model and the role of case managers will be explained using clear and simple language. During interviews, a semi-structured interview guide with probes will be used to elicit detailed responses. Interviews will be recorded in either video or audio format. A pilot interview with 2\u0026ndash;3 participants will be conducted before the onsite investigation to refine the interview questions. Sociodemographic characteristics such as age, education, income, and the number and types of chronic conditions, will be collected. Additionally, the Chinese version of the Barthel Scale/Index (BI) will be used to assess the older adults\u0026rsquo; levels of Activities of Daily Living (ADL). A total of 30 participants will be recruited, and the final sample size will be determined based on data saturation. The sample of open-ended questions and probes can be found in supplement file 1.\u003c/p\u003e \u003cp\u003eQualitative data analysis plan\u003c/p\u003e \u003cp\u003eRaw data will be managed using NVIVO 11 or ATLAS.ti8. Trained investigators will transcribe the interviews verbatim, and an additional investigator will conduct a data audit. Thematic and coding analysis will be conducted using both inductive and deductive approaches, guided by the PRISMA model. The data will be analysed using the framework method, which consists of six steps: (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e) reviewing transcripts and noting initial ideas about themes; (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e) developing a coding system based on the transcripts; (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e) conducting weekly team meetings to identify recurring themes; (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e) comparing themes across participants through constant comparative analysis; (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e) defining and naming themes; (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e) compiling a written report of the findings.\u003c/p\u003e \u003cp\u003ePhase II: Questionnaire development and validation\u003c/p\u003e \u003cp\u003eThe aim of Phase II is to develop and validate a questionnaire based on the PRISMA model and Phase I outcomes. This tool will be used to assess the levels of expectations for integrated care through case managers among older adults, examining both general and specific expectations, as well as their sociodemographic characteristics correlates.\u003c/p\u003e \u003cp\u003eQuestionnaire design and measurement\u003c/p\u003e \u003cp\u003eThe questionnaire will be divided into two sections: 1) sociodemographic characteristics, including age, income, number and type of chronic conditions. The BI Scale for ADL will be assessed using a combined tool; 2) items of expectations related to integrated care through case managers. This section is informed by qualitative outcomes from Phase I, with variables derived from coded data and scales based on identified themes. Questionnaire items are constructed using direct quotations from the qualitative study, aligning with the PRISMA model and emerging codes from Phase I. To quantify the level of expectations, a 5-point Likert scale will be employed, allowing for categorisation of responses into three groups: low, medium, and high expectations. This categorisation can be applied at both the item level and construct level, based on the scale's properties. The final questionnaire is anticipated to consist of approximately 50 items in the expectations section, with a completion time of around 30 minutes.\u003c/p\u003e \u003cp\u003eQuestionnaire validity and reliability\u003c/p\u003e \u003cp\u003eThe face and content validity of the items in the questionnaire will be assessed by a panel of at least six experts, including nurses, geriatricians, statisticians, healthcare case managers, social workers, and older adults. The feedback provided by the panel members will be used to calculate the content validity index (CVI) for each item included in the questionnaire (\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e). The relevance, comprehensibility, and comprehensiveness of the items will be evaluated using the COnsensus-based Standards for the selection of health status Measurement INstruments check list (\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e). To assess structural validity, a pilot study will be conducted.\u003c/p\u003e \u003cp\u003eThe structural validity of the questionnaire will be assessed through a pilot study, employing Exploratory Factor Analysis (EFA) to examine the underlying factor structure. Factors with an eigenvalue greater than 1 will be retained, while items with factor loadings below 0.40 or significant cross-loadings will be excluded (\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e). Structural Equation Modeling (SEM) will be used to evaluate the model fit, ensuring that the data supports the hypothesized factor structure. Internal consistency of the questionnaire will be evaluated using Cronbach's alpha, with a threshold of 0.70 or higher indicating acceptable reliability (\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e). Additionally, the reliability of the questionnaire will be assessed using intra-class coefficients (ICC) to determine intra-rater test-retest reliability. A random sample of at least 50 participants will be selected to complete the questionnaire twice, with a one-month interval between administrations (\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e). An ICC value between 0.50 and 0.75 will be interpreted as moderate reliability, while a value of 0.75 or higher will be considered indicative of good reliability (\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e).\u003c/p\u003e \u003cp\u003ePhase III: A quantitative study through a survey\u003c/p\u003e \u003cp\u003eIn Phase III, a survey will be conducted to examine the expectations of integrated care through case managers among Chinese community-dwelling older adults and their associated sociodemographic characteristics. The survey will use a validated questionnaire that has been developed in Phase II. The questionnaire will be provided in Chinese either through a web-based platforms such as wjx.cn or as printed hard copies. Online participants will need to provide their Informed Consent Form by clicking a response button, while onsite participants will be required to provide a signature. Additionally, a data integration approach will be applied to combine the quantitative and qualitative data from Phase I and Phase III. This approach aims to enhance the understanding of complex phenomena, examine hypotheses, and deepen the findings. Based on the outcomes, an evidence-based framework will be formulated to optimise healthcare delivery for Chinese community-dwelling older adults.\u003c/p\u003e \u003cp\u003eSetting\u003c/p\u003e \u003cp\u003eIn China, there is an uneven distribution of population and regional economic development, with a gradually declining trend from east to west (\u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e). The survey will be conducted in three major cities: Wenzhou, Taiyuan, and Hainan. Wenzhou, located almost at the center of China's eastern coast, has a significant aging population. Older adults in Wenzhou prefer to reside in their homes and communities and receive integrated healthcare services align with Chinese culture values (\u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e). Wenzhou is known as a pioneer in China's private economy, with a thriving small and medium-sized enterprise sector. It is considered one of the economically developed coastal regions in the east of China (\u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e). Taiyuan, the capital city of Shanxi province, represents the west of China. The average income in this area is slightly below the national average (\u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e). The number of older adults aged 60 and above in Taiyuan has exceeded 21.9% of the total population, indicating that it has entered a super-ageing society (\u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e51\u003c/span\u003e). Hainan (island), China's southernmost province, is also experiencing rapid ageing. The number of local older adults aged 60 and above in Hainan has reached 1.46\u0026nbsp;million, accounting for 15.5% of the total local population (\u003cspan citationid=\"CR52\" class=\"CitationRef\"\u003e52\u003c/span\u003e). Due to its prosperous economy and pleasant living environment, Hainan has become a highly sought-after location for older individuals, particularly during winter migration from 27 different provinces across China (\u003cspan citationid=\"CR53\" class=\"CitationRef\"\u003e53\u003c/span\u003e, \u003cspan citationid=\"CR54\" class=\"CitationRef\"\u003e54\u003c/span\u003e). The samples from Hainan are more representative of a large ageing population.\u003c/p\u003e \u003cp\u003eParticipants and sample size estimation\u003c/p\u003e \u003cp\u003eIn accordance with the sample in the qualitative study, the quantitative study will recruit older adults who meet the following criteria: 1) aged\u0026thinsp;\u0026ge;\u0026thinsp;60, 2) living independently in the community, 3) having at least one chronic condition, and 4) visiting a hospital or clinic more than three times a year to manage their chronic diseases. Individuals who are unwilling to participate, have language difficulties, or cognitive impairments will be excluded. Based on an expected 18.8% level of expectations of chronic disease management services among Chinese older adults (\u003cspan citationid=\"CR55\" class=\"CitationRef\"\u003e55\u003c/span\u003e), a 95% confidence level with a two-sided and 5% margin of error, the minimum required sample size was 235. However, a target sample size of 354 (118 in each city) is set with a response rate of approximately 80% for non-response and incompletion rates.\u003c/p\u003e \u003cp\u003eSampling process\u003c/p\u003e \u003cp\u003eA stratified random sampling method will be used to ensure that the sample accurately represents the diversity of older adults. Six community medical centres will be randomly selected from three cities, with two centers chosen from each city. Initially, six enumerators (two in each city) will propose four communities and specialised geriatric hospitals in each city where the ageing population exceeds 21% of the community's total population. Two of these communities will then be randomly chosen to ensure an unbiased representation. Recruitment will be carried out through posters, flyers, announcements in medical centers, and various outreach methods such as online platforms and community events to maximise participation. Participants will be requested to provide demographic information, which will be used to stratify the sample based on age and presence of chronic diseases prior to randomly selecting participants within each stratum. This approach ensures that the sample reflects the diversity of older adults across different community medical centers and cities.\u003c/p\u003e \u003cp\u003eData collection process\u003c/p\u003e \u003cp\u003eOnsite investigators, comprising of at least one investigator and one research assistant in each city, will be responsible for overseeing the data collection process. At these selected sites, investigators will screen older adults based on the inclusion criteria to determine their eligibility. Those who meet the criteria will then be approached and provided with detailed information of the study. Simultaneously, participants will be informed about the study's objectives and asked to provide their consent. Informed consent will be obtained through either signed forms for onsite participants or electronic consent for online participants. To facilitate accurate data collection, participants will have the option to provide their telephone numbers, which will enhance the study's credibility and support convenient recruitment for intra-rater test-retest. Collected data will be entered into a database and undergo a double-checking process by investigators and research assistants to ensure accuracy and completeness.\u003c/p\u003e \u003cp\u003eMeasurement\u003c/p\u003e \u003cp\u003eAt the beginning of the questionnaire, a description of the modified PRISMA model in simple Chinese language will be provided to explain the concept of integrated care through a single entry point by a case manager. Participants will be asked to repeat the PRISMA model to confirm their understanding of the fundamental concept.\u003c/p\u003e \u003cp\u003eSociodemographic characteristics\u003c/p\u003e \u003cp\u003eSpecific age and hospitalisation within the previous year will be collected as numerical variables. Other variables will be categorized as descriptive variables. For example, gender (male or female), health status (healthy, living with one chronic disease, and living with two or more chronic diseases), monthly income (\u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(\\:\u0026lt;\\)\u003c/span\u003e\u003c/span\u003e375 USD, 375\u0026ndash;749 USD, \u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(\\:\u0026gt;\\)\u003c/span\u003e\u003c/span\u003e749 USD), education (no formal education, elementary school, middle school, high school, bachelor\u0026rsquo;s degrees or above), occupation (employed, unemployed, retired), insurance (No insurance, UEBMI=Urban Employee Basic Medical Insurance, URBMI=Urban Resident Basic Medical Insurance, and NRCMI=New Rural Cooperative Medical Insurance), number of children (no child, 1 child, 2 children, and 3 or more children), and living arrangements (alone, with a partner, with a child or children, with a partner and children, and living with others such as a housemaid).\u003c/p\u003e \u003cp\u003eBarthel Index (BI)\u003c/p\u003e \u003cp\u003eThis section will include ten items to aid in evaluating and categorising the level of ADL among participants. The BI scale was developed to assess a patient\u0026rsquo;s self-care abilities in ten areas, including control of bowel and bladder. The patient is scored ranging from 0 to 15 points in different categories, based on their need for assistance, such as in feeding, bathing, dressing, and walking (\u003cspan citationid=\"CR56\" class=\"CitationRef\"\u003e56\u003c/span\u003e). The Chinese version of the BI Scale has been validated and extensively implemented in various clinical assessment settings (\u003cspan citationid=\"CR57\" class=\"CitationRef\"\u003e57\u003c/span\u003e, \u003cspan citationid=\"CR58\" class=\"CitationRef\"\u003e58\u003c/span\u003e). The BI is conventionally divided into four levels of scores using the following divisions: 100\u0026thinsp;\u0026minus;\u0026thinsp;91 (complete independence), 90\u0026thinsp;\u0026minus;\u0026thinsp;61 (slight level of dependence), 60\u0026thinsp;\u0026minus;\u0026thinsp;21 (moderate dependence), and \u0026le;\u0026thinsp;20 (severe dependence) (\u003cspan citationid=\"CR59\" class=\"CitationRef\"\u003e59\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eExpectation section\u003c/p\u003e \u003cp\u003eThe variables in the final version of the questionnaire will be categorised as individual items and groups within the construct to measure participants\u0026rsquo; overall and specific expectations of integrated care. A 5-point Likert scale ranging from 1 to 5 will be used to indicate expectations from low to high.\u003c/p\u003e \u003cp\u003eData analysis for the quantitative study\u003c/p\u003e \u003cp\u003eThe IBM Statistical Package for the Social Sciences (SPSS 26) will be utilised to input and analyse quantitative data. Data from online questionnaires will be automatically transferred to SPSS, while data from hard-copy questionnaires will be manually entered into the dataset. The mean expectation scores will be categorised into tertiles, representing the lowest, middle, and highest levels of expectations. Chi-square tests will be conducted to explore the relationship between sociodemographic characteristics and the different expectation categories for integrated care. A significance level of \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05, with a 95% confidence interval, will be used to determine statistical significance. Multiple logistic regression models will be employed to analyse the association of independent variables with the levels of expectation, using the lowest tertile of expectation as the reference group. Independent variables with a \u003cem\u003ep\u003c/em\u003e-value\u0026thinsp;\u0026lt;\u0026thinsp;0.20 from univariable regression analysis will be considered for inclusion in the final multiple regression model. The presence of multicollinearity among independent variables will be evaluated using a tolerance threshold of \u0026lt;\u0026thinsp;0.4 or a Variance Inflation Factor (VIF)\u0026thinsp;\u0026ge;\u0026thinsp;2.5. The adequacy of model fitting will be evaluated, and Q-Q plots for normality, residual plots for linearity and homogeneity assumptions will be examined. Skewness and kurtosis statistics will be utilised to assess the statistical assumptions of survey item responses. A moderate normality threshold of 2.0 and 7.0 will be applied for skewness and kurtosis, respectively, in the assessment of multivariate normality (\u003cspan citationid=\"CR60\" class=\"CitationRef\"\u003e60\u003c/span\u003e).\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study aims to develop and evaluate an evidence-based integrated care model tailored to the specific needs of Chinese community-dwelling older adults with complex healthcare needs, with a focus on chronic diseases, multimorbidity, and physical impairments (\u003cspan citationid=\"CR61\" class=\"CitationRef\"\u003e61\u003c/span\u003e). By incorporating elements from the PRISMA model and considering the specific expectations and conditions of the ageing population in China, this study strives to promote integrated care through a centralised point of access managed by a case manager. This approach addresses significant gaps in current healthcare provision and aims to improve the quality, accessibility, and efficiency of services, thereby enhancing care for China's ageing population.\u003c/p\u003e \u003cp\u003eThe utilisation of healthcare case management services has shown notable benefits for the healthcare of older adults living in the community, particularly those who are frail (\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e). This approach to healthcare coordination ensures that older adults with multiple health conditions receive appropriate care without any gaps or duplications, as care is coordinated across multiple healthcare providers (\u003cspan citationid=\"CR62\" class=\"CitationRef\"\u003e62\u003c/span\u003e, \u003cspan citationid=\"CR63\" class=\"CitationRef\"\u003e63\u003c/span\u003e). By identifying and managing health conditions in their early stages, case managers can help mitigate the risk of complications and hospitalisations, resulting in improved health outcomes (\u003cspan citationid=\"CR64\" class=\"CitationRef\"\u003e64\u003c/span\u003e). The personalised support and care delivered by case managers can also enhance patient satisfaction with their healthcare experience (\u003cspan citationid=\"CR65\" class=\"CitationRef\"\u003e65\u003c/span\u003e, \u003cspan citationid=\"CR66\" class=\"CitationRef\"\u003e66\u003c/span\u003e). Additionally, this approach can contribute to disease detection, thereby preventing costly hospitalisations and making care more cost-effective (\u003cspan citationid=\"CR67\" class=\"CitationRef\"\u003e67\u003c/span\u003e, \u003cspan citationid=\"CR68\" class=\"CitationRef\"\u003e68\u003c/span\u003e). Healthcare case management services can also facilitate access to resources and services that enhance the quality of life for older adults, such as transportation, social activities, and home health services (\u003cspan citationid=\"CR65\" class=\"CitationRef\"\u003e65\u003c/span\u003e, \u003cspan citationid=\"CR69\" class=\"CitationRef\"\u003e69\u003c/span\u003e). Furthermore, support is provided to family members and informal caregivers, assisting them in managing the physical, emotional, and financial demands associated with caring for older adults (\u003cspan citationid=\"CR70\" class=\"CitationRef\"\u003e70\u003c/span\u003e, \u003cspan citationid=\"CR71\" class=\"CitationRef\"\u003e71\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eExtensive research has been conducted on integrated care models for older adults, particularly in Western countries where these models have been implemented to varying degrees of success. For example, the PRISMA model has been widely studied in Canada and has demonstrated improvements in continuity of care, reduced hospitalisations, and improved patient satisfaction (\u003cspan citationid=\"CR72\" class=\"CitationRef\"\u003e72\u003c/span\u003e). Similarly, other integrated care models, such as the Chronic Care Model (CCM) in Europe (\u003cspan citationid=\"CR73\" class=\"CitationRef\"\u003e73\u003c/span\u003e) and the Kaiser Permanente model in America have shown positive outcomes in managing chronic diseases among older adults (\u003cspan citationid=\"CR74\" class=\"CitationRef\"\u003e74\u003c/span\u003e). However, the PRISMA model is better suited to the Chinese healthcare system.\u003c/p\u003e \u003cp\u003eIn the context of China, the existing healthcare system is fragmented and ill-prepared to provide a comprehansive continuum of care for chronic diseases. Therefore, there is a pressing need to develop integrated and efficient care, particularly for older adults (\u003cspan citationid=\"CR75\" class=\"CitationRef\"\u003e75\u003c/span\u003e). China's regional healthcare system, led by the government, integrates large and medium-sized hospitals with primary healthcare institutions to form a collaborative medical community. This facilitates resource sharing, access to advanced facilities, and expert guidance, enabling the delivery of safe, effective, and continuous integrated care, particularly for older adults with multiple comorbidities (\u003cspan citationid=\"CR76\" class=\"CitationRef\"\u003e76\u003c/span\u003e). Despite active exploration by experts to identify integrated care models suitable for China, most studies primarily rely on literature reviews. Fewer studies employ qualitative and quantitative research to validate these models among elderly populations and stakeholders (\u003cspan citationid=\"CR77\" class=\"CitationRef\"\u003e77\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThis study significantly contributes to the field of geriatric care by proposing and evaluating an integrated care model tailored to the specific needs of Chinese older adults. By employing a mixed-methods approach that combines qualitative and quantitative data, the comprehensive understanding of the expectations and needs of older adults towards integrated care will be enhanced. The findings of this study have the potential to inform policy decisions, guide the implementation of integrated care models, and ultimately improve health outcomes and quality of life for Chinese older adults.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003eEthics approval and consent to participate\u003c/p\u003e\n\u003cp\u003eEthical approval for this study has been obtained from\u0026nbsp;Zhejiang Dongfang Polytechnic, China\u0026nbsp;(Approval No. GZSQ202408120010). Participants will be provided with a respondent Information Sheet and Informed Consent Form, which they will be required to sign before participating in interviews and surveys.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eConsent for publication\u003c/p\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e\n\u003cp\u003eAvailability of data and materials\u003c/p\u003e\n\u003cp\u003eThe datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003eCompeting interests\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003eFunding\u003c/p\u003e\n\u003cp\u003eThis study is part of a project financially supported by the China Association of Social Workers (CASW) and Zhejiang Dongfang Polytechnic, China. As a public interest social research project, the funders have no role in the study design, execution, analysis, interpretation of data, or the decision to submit results.\u003c/p\u003e\n\u003cp\u003eAuthors\u0026apos; contributions\u003c/p\u003e\n\u003cp\u003eAll authors contributed to writing the manuscript. ZYY initiated and contributed to the design of the study. In the ongoing process, ZYY will be in charge of implementing the study, while TYH will translate interview transcripts into English and audit the raw data. ZH will assist in conducting on-site data collection. All authors have read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003eAcknowledgements\u003c/p\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e\n\u003cp\u003eAuthors\u0026apos; information\u003c/p\u003e\n\u003cp\u003eZYY is currently leading the development of academic disciplines for smart ageing at the School of Smart Health and Wellness, Health Medical College, Zhejiang Dongfang Polytechnic, China. This interdisciplinary field, situated at the intersection of health, engineering, and social sciences, focuses on enhancing China\u0026apos;s public health system and promoting healthy ageing.\u003c/p\u003e\n\u003cp\u003eTYH is affiliated with Jiangxi Science and Technology Normal University, China. His research interests include education for older adults and cross-cultural social services.\u003c/p\u003e\n\u003cp\u003eZH is the Director of the Health Management Department at the School of Smart Health and Wellness, Health Medical College, Zhejiang Dongfang Polytechnic, China. Her research interests include traditional Chinese medicine, geriatric health management, and community-based health planning and services.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eXinhua. 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Chin Nurs Res. 2022;36(17).\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Healthcare, Case Manager, Chronic Diseases, Older Adults, Community, China","lastPublishedDoi":"10.21203/rs.3.rs-4901154/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4901154/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe rising prevalence of chronic diseases among older adults in China calls for a more robust and efficient healthcare system. The current system, being fragmented and insufficient, fails to deliver comprehensive care for chronic diseases. There is a pressing need for tailored and integrated care solutions for older adults, which would facilitate resource sharing, improve access to advanced facilities, provide expert guidance, and ensure safe and effective care for those with multiple comorbidities.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eEmploying the PRISMA model recommended by the World Health Organization, this study suggests the use of a case manager to improve the delivery of publicly funded healthcare in the community. An exploratory sequential mixed methods approach will be implemented to investigate the acceptability of the PRISMA integrated care model and to identify the realistic needs, expectations, and associated sociodemographic characteristics of Chinese community-dwelling older adults respectively. An evidence-based integrated care model will be captured that can optimise healthcare delivery.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDiscussion\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eBy incorporating elements from the PRISMA model and considering the specific expectations of older adults, this study strives to promote integrated care through a centralised point of access managed by a case manager. This approach addresses significant gaps in the current healthcare provision and aims to improve the quality, accessibility, and efficiency of services, thereby improving care for the community. The findings of this study have the potential to inform policy decisions, guide the implementation of integrated care delivery, and ultimately improve health outcomes and the quality of life for older adults in China.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eProtocol Registration:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study protocol has been registered on osf.io\u003c/p\u003e\n\u003cp\u003e(Registration DOI: \u003ca href=\"https://doi.org/10.17605/OSF.IO/825AH\"\u003ehttps://doi.org/10.17605/OSF.IO/825AH\u003c/a\u003e).\u003c/p\u003e","manuscriptTitle":"Chinese Community-dwelling Older Adults’ Expectations regarding the Delivery of Integrated Care through Case Managers: A Mixed Methods Study Protocol","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-10-15 11:02:31","doi":"10.21203/rs.3.rs-4901154/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"3d901c7a-dcef-4db4-bfcb-5df7670cbf69","owner":[],"postedDate":"October 15th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2024-12-12T17:08:11+00:00","versionOfRecord":[],"versionCreatedAt":"2024-10-15 11:02:31","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-4901154","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4901154","identity":"rs-4901154","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}