Exploring patient-centered care delivery in elderly outpatient settings: A scoping review and recommendations for implementation in countries with low and middle income

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Long-term management and patient involvement are particularly relevant in outpatient settings. This scoping review provides a comprehensive overview of existing evidence on PCC for older adults, mapping definitions, elements, stakeholder perspectives, barriers to implementation, and practical models of PCC adoptation. Additionally, it offers actionable recommendations for integrating PCC into healthcare systems in low- and middle-income countries (LMICs). Methods: A systematic search was conducted in PubMed, Web of Science, Scopus, and Google Scholar on 2 August 2024, with no publication year restrictions, to capture the full range of available evidence. We adhered to the JBI methodology for scoping reviews. Data synthesis involved a descriptive approach with findings contextualized to support the integration of PCC into LMIC healthcare systems. Results: From an initial pool of 1474 sources, 76 records were included for data extraction. The majority of PCC definitions shared key themes, including partnership with patients in decision-making, a holistic approach to patient care, and coordination across multiple disciplines. The review revealed that while patients and providers shared the goal of achieving high-quality, personalized care, their perspectives on PCC differed. Providers emphasized systemic efficiency, teamwork, and care coordination, whereas patients valued accessibility, emotional connection, trust, and relational aspects of care. Key barriers to implementing PCC included infrastructural challenges, financial and human resource limitations, transportation issues, and time constraints. Successful models of PCC often involved multidisciplinary teams and community-based collaborations, which were particularly effective in managing chronic diseases in elderly patients. Conclusions: This review highlights the potential of PCC in enhancing the quality of care for older adults in outpatient settings. Building on our findings, a phased approach focusing on older adults with multimorbidity is recommended for LMICs like Iran, with an emphasis on integrating both primary and specialized care. Our proposed seven-dimensional PCC model includes access to care, proactive care, patient empowerment, integration into care pathways, a whole-person approach, coordinated care, and shared decision-making, tailored for LMIC contexts to improve care for elderly patients. Patient-Centered Care Elderly Outpatient Low and Middle Income Countries Healthcare Model Chronic Disease Management Person-Centered Care Aged Figures Figure 1 Figure 2 1. Background The shift from disease-centered to patient-centered care (PCC) has become essential in advancing healthcare services and patient outcomes, especially in the context of multiple chronic diseases [1, 2]. Identified as one of six core elements in the healthcare quality framework by the Institute of Medicine, PCC highlights the need to customize care navigation to the unique needs, preferences, and values of individual patients, encouraging collaboration with healthcare providers as equal partners toward shared goals [3, 4]. In the past decade, it has gained greater importance in elderly care due to the aging population and the increasing prevalence of chronic conditions that require continuous, patient-centered interventions [5, 6]. Older adults in outpatient settings often face unique challenges, including the need for managing multimorbidity, polypharmacy, and functional limitations [7]. Based on the World Population Prospects 2022, the population of adults aged 65 and above has been projected to increase globally from 10% in 2022 to 16% by 2050 [8]. In United States (US), despite being the smallest age group population, they account for approximately 37% of total healthcare spending [9]. In addition, this population attend ambulatory care visits nearly twice as often as younger individuals, representing 26% of all physician office visits and 34% of prescription medication usage [10–12]. Traditional healthcare models, often designed for acute, episodic care, may not adequately meet the ongoing needs of this population. This calls for a more coordinated approach to healthcare delivery [6]. PCC seeks to improve not only clinical outcomes but also patient satisfaction, empowerment and the overall healthcare experiences, particularly in outpatient settings where long-term management and patient involvement are critical [4, 13]. However, previous studies have shown inconsistent findings regarding better clinical outcomes and cost savings in this population after implementing patient-centered initiatives. For instance, in a longitudinal study of over one million patients aged 65 years and older, improvement or decline in patient-centered medical home (PCMH) implementation showed no significant change in the use of high-cost healthcare services among patients at each clinic site [14]. In another patient-centered practice model for low back pain in community-dwelling elderly patients, interprofessional practices over one year of trial showed no between-group differences in pain intensity and related disability score, compared to usual care [15]. These findings suggest that while PCC has many theoretical benefits, practical implementation may yield variable outcomes depending on context and model framework. A sharper definition of PCC and its dimensions is critical for efficiently incorporating this concept into healthcare systems. Reviewing previous literature demonstrates that different healthcare organizations often operationalize PCC in diverse ways, with some incorporating only selected domains of PCC or single patient-centered interventions into their existing care, leading to inconsistent practices and outcomes across settings [6, 16]. This scoping review aimed to explore existing evidence on PCC for elderly patients in outpatient settings to provide a comprehensive overview of PCC definitions, key elements, and perspectives from policymakers, healthcare providers, and patients/caregivers. It also mapped common barriers to implementing PCC models and the effectiveness of various PCC adoptations and interventions for elderly care. Additionally, given the considerable limitations in delivering patient-centered care to elderly outpatients in LMICs, this review provided recommendations for integrating PCC into their healthcare systems to enhance care quality for the aging population. 2. Methods A scoping review approach was chosen over a systematic review because it allows for a comprehensive and structured mapping of the current body of literature, which is crucial for addressing our broad objectives in examining various aspects of PCC for elderly patients in outpatient settings [17]. This scoping review followed the Joanna Briggs Institute (JBI) methodology for scoping reviews [17]. Our review is reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) 2018 statement [18]. No protocol for this review has been published or registered. 2.1. Review Questions How is PCC defined in the context of elderly outpatient healthcare? What are the common elements of PCC models in elderly outpatient care? What perspectives do key stakeholders (patients/caregivers, healthcare providers, and policymakers) hold on the implementation of PCC in outpatient settings for elderly patients? What are the barriers to implementing PCC in outpatient settings for the elderly? What are the practical models of PCC adoptation or patient-centered interventions incorporated into existing care pathways for older adults in outpatient centers? What are the reported outcomes associated with PCC models or interventions in elderly outpatient settings? 2.2. Inclusion and Exclusion Criteria We used the Population, Concept, and Context framework, recommended by JBI to identify eligible sources of evidence: Population: Adults aged 65 and above. We also included studies that mean or median age of study participants is ≥ 65 years. Studies with mixed-age populations were excluded unless they provided separate or generalizable findings specific to older adults. Concept: The review aimed to explore the delivery and components of PCC. This included definitions of PCC, core elements, perspectives from patients, healthcare providers, and policymakers, as well as barriers to and outcomes of PCC implementation. In addition, we included studies assessing patient-centered interventions integrated into existing care pathways in the review. Studies focusing solely disease-specific interventions without a broader PCC concept were excluded. Context: Outpatient healthcare settings providing long-term chronic care delivery and can be from primary care offices, day care hospitals, specialty clinics, rehabilitation and therapy centers, dialysis centers. Institutions/ centers focusing end stage and palliative care, urgent care centers such as retail clinics, home healthcare services and telehealth without broader outpatient component were excluded. Studies were included if they took place in outpatient healthcare settings providing long-term chronic care, such as primary care offices, specialty clinics, day care hospitals, rehabilitation centers, and dialysis centers. Studies in end-stage or palliative care facilities, urgent care centers including retail clinics, home healthcare services, or telehealth services without a broader outpatient care component were excluded. Types of evidence sources: This scoping review will consider all types of literature including experimental and quasi-experimental study designs, observational studies, qualitative studies, and reviews for inclusion. Protocols and grey literature that meet the inclusion criteria will also be considered. 2.3. Search Strategy The search strategy was developed iteratively. Initially, a preliminary search was conducted in MEDLINE on 16 July 2024 to identify key articles on the topic. Text words in titles and abstracts of these articles, as well as relevant index and MeSH terms were used to develop a full search strategy aligned with the Population / Concept / Context framework: “patient-centered*” OR “patient centered*” OR “patient-centred*” OR “patient centred*” OR “person-centered*” OR “person centered*” OR “patient-focused” OR “patient focused” OR “value-based care” OR “value-based healthcare” AND “elder*” OR “old” OR “older*” OR “senior*” OR “geriatric” OR “aging” AND “outpatient*” OR “out-patient*” OR “ambulatory” The resulting search strategy, including all identified keywords and index terms, was adapted for additional databases. The review process involved systematic searches across PubMed, Web of Science, Scopus, and Google Scholar on 2 August 2024. The reference list of included sources of evidence were screened for additional studies. Only studies published in English were included, with no restrictions on the publication year to capture the full range of available evidence. Additionally, grey literature from healthcare and governmental organizations was included to capture non-academic sources relevant to PCC. 2.4. Evidence Screening and Selection Following the search, all identified citations were imported into EndNote 21.3 (Clarivate Analytics, PA, USA), and duplicates removed. In the first step of screening, two independent reviewers screened titles and abstracts to assess eligibility based on the inclusion criteria, with potentially relevant sources retrieved in full text. The full text of selected citations was further evaluated in detail against the inclusion criteria by the same two independent reviewers, and reasons for exclusions were recorded for reporting. Any disagreements between reviewers were resolved through discussion, or by consulting the corresponding author. The results of the search and the study inclusion process is reported in full in the final scoping review and presented in a PRISMA flow diagram [18]. Since the goal of this review was to map the current body of evidence on PCC in elderly outpatient settings, we did not conduct a risk of bias assessment. 2.5. Data Extraction Data extraction was conducted using a structured form designed in a spreadsheet to capture study characteristics such as publication year, country, study design, target population, PCC definitions, core elements, PCC delivery models, interventions, barriers, and reported outcomes. Initially, three team members independently extracted data from the first five studies to assess consistency. Following this pilot extraction, their agreement was evaluated, and based on their recommendations, perspectives from key stakeholders were added to both the research questions and the extraction sheet to enhance comprehensiveness. Any discrepancies between team members during extraction were resolved by the corresponding author. 2.6. Data Analysis The data were synthesized narratively to highlight PCC definitions, elements, stakeholder perspectives, barriers and effectiveness in elderly outpatient settings. Tables will be used to summarize study characteristics and thematic findings. Findings were contextualized to support PCC integration into LMICs’ healthcare systems. 2.7. Declaration of AI-Assisted Technologies Use During the preparation of this work, the authors used ChatGPT in order to refine language and clarity. The authors reviewed and edited the content as needed and take full responsibility for the content of the publication. 3. Results A total of 1474 sources of evidence were identified through the database search. After the removal of 340 duplicates, 1134 records remained for title and abstract screening against the inclusion criteria. From these, we retrieved 112 records for full text review, of which 59 met the inclusion criteria and with 17 additional studies identified from the reference lists of included sources, resulted in final 76 records for data extraction [Figure 1]. The included studies, published between 2000 and 2024, represent research from 15 countries, with most originating from the US. Of note, more than 95% of included studies were conducted in countries with high-income economies as classified by the World Bank for the current 2025 fiscal year [19]. The majority of studies employed experimental and quasi-experimental designs (25) and qualitative research methods (22). The remaining studies utilized theoretical or conceptual frameworks (14), mixed methods research (7), systematic reviews (6) and observational studies (2). The studies addressed a broad range of PCC concept in elderly outpatient settings, including definitions and conceptual frameworks of PCC, stakeholder perspectives, barriers to its implementation, and PCC-aligned care delivery models or interventions along with their outcomes. 3.1. Definitions and Core Elements of PCC The definitions and core elements of PCC varied across frameworks and organizations, reflecting diverse perspectives on how to approach and enact it, as PCC is still an evolving area of healthcare [Table 1 ]. However, most definitions shared overarching themes, including partnership with the patient (and caregivers) in decision-making, seeing the whole person in the patient and coordination of care across multiple disciplines. In addition to the “patient-centered care” term, several other related terminologies are used by frameworks, including person-centered care [20–27], people-centered care [28], relationship-centered care [20, 29], and client-centered care [16]. Majority of included studies adopted the definition by the Institute of Medicine, emphasizing respectful, quality care guided by patient’s goals, needs and expressed desires [3]. Core components of patient centeredness include key components of trust-building provider-patient relationships [22, 23, 28], dignity [26, 30–32] and creating an enabling environment [21, 25, 26, 28, 30]. Table 1 Frameworks of PCC and their principles. Framework Quoted definition Quoted dimensions Institute of Medicine (now, known as the National Academy of Medicine) “Providing care that is respectful of and responsive to individual patient preferences, needs, and values and ensuring that patient values guide all clinical decisions [3].” Endorsed seven dimensions proposed by Gerteis et al.: - “Respectful to patients’ values, preferences, and expressed needs - Transition and community - Involvement of family and friends - Coordination and integration of care - Provide information, communication, and education - Physical comfort - Emotional support – relieving fear and anxiety [31]” Picker Institute [23] “Putting people at the heart of health and social services, including care, support, and enablement. It is an approach where users are recognized as individuals, encouraged to play an active role in their care, and where their needs and preferences are understood and respected.” - “Involvement in decisions and respect for preferences - Continuity of care and smooth transitions - Involvement and support for family and carers - Effective treatment by trusted professionals - Clear information, communication and support for self-care - Attention to physical and environmental needs - Emotional support, empathy and respect - Fast access to reliable healthcare advice” King’s Fund [20] - “Integrated care centred around the individual’s needs - Healthy, active ageing and supporting independence - Living well with simple or stable long-term conditions - Living well with complex co-morbidities, dementia and frailty - Rapid support close to home in times of crisis - Good acute hospital care when needed - Good discharge planning and post-discharge support - Good rehabilitation and re-ablement after acute illness or injury - High-quality nursing and residential care for those who need it - Choice, control and support towards the end of life” International Alliance of Patients' Organizations [30] “Patient-centred healthcare is designed, organized and practised with patient at the centre." - “Respect - Choice and engagement - Patient involvement in health policy - Access and support - Information” Centers for Medicare & Medicaid Services [22] “Integrated health care services delivered in a setting and manner that is responsive to individuals and their goals, values and preferences, in a system that supports good provider–patient communication and empowers individuals receiving care and providers to make effective care plans together.” - “Care that’s guided and informed by patients’ goals, preferences, and values - Success measured by patient-reported outcomes - Integrated and coordinated care across health systems, providers, and care settings - Managing chronic and complex conditions - Relationships built on trust and a commitment to long-term well-being” WHO Framework for Integrated People-Centered Health Services [28] “An approach to care that consciously adopts individuals’, carers’, families’ and communities’ perspectives as participants in, and beneficiaries of, trusted health systems that are organized around the comprehensive needs of people rather than individual diseases, and respects social references.” - “Empowering and engaging people and communities - Strengthening governance and accountability - Reorienting the model of care - Coordinating services within and across sectors - Creating an enabling environment” Bisognano and Schummers [36] (Institute for Healthcare Improvement) “Flipping healthcare means flipping the balance of care from the hospital to the community; the balance of delivery from individual providers to care teams; the balance of power from the provider to the patient and family; the balance of costs from treatment to prevention and co-production; and the balance of emphasis from volume to value and from healthcare to health. Truly person centred healthcare must consider and seek to understand the entire spectrum of social and economic factors that affect a person’s health, not merely the narrow slice of how or why a patient presents at the hospital or clinic.” National Health Service [21] “Focusing care on the needs of individual. Ensuring that people's preferences, needs and values guide clinical decisions, and providing care that is respectful of and responsive to them. Health and wellbeing outcomes need to be co-produced by individuals and members of the workforce working in partnership, with evidence suggesting that this provides better patient outcomes and costs less to health and care systems.” - “Services are created in partnership with citizens and communities - Personalised care - Coordinated care - Patient empowering - Involvement and support of carers - Focus is on quality and narrowing inequalities” Health Foundation [26] “In person-centred care, health and social care professionals work collaboratively with people who use services. Person-centred care supports people to develop the knowledge, skills and confidence they need to more effectively manage and make informed decisions about their own health and health care. It is coordinated and tailored to the needs of the individual. And, crucially, it ensures that people are always treated with dignity, compassion and respect.” - “Affording people dignity, compassion and respect - Offering coordinated care, support or treatment - Offering personalised care, support or treatment - Supporting people to recognise and develop their own strengths and abilities to enable them to live an independent and fulfilling life” Mead and Bower [117] - “Biopsychosocial perspective - Patient-as-person - Sharing and power of responsibility - Therapeutic alliance - Doctor-as-person” Langberg et al. [118] - “Biopsychosocial perspective - Patient-as-person - Sharing and power of responsibility - Therapeutic alliance - Doctor-as-person - Coordinated care” Institute for Patient- and Family-Centered Care [32] “An approach to the planning, delivery, and evaluation of health care that is grounded in mutually beneficial partnerships among health care providers, patients, and families.” - “Participation in care and decision-making at the level they choose - Respect and dignity - Information sharing - Collaboration” McCormack & McCance [27] - “Working with patient’s beliefs and values - Engagement - Shared decision making - Providing sympathetic presence - Providing for physical needs” Epstein et al. [37] - “An informed and involved patient and family - Receptive and responsive health professionals who can focus on the disease and knowing the patient - A well-coordinated and well-integrated health care environment that supports the efforts of patients, families and their clinicians” Lusk and Fater [119] - “Encouraging patient autonomy - Individualizing patient care - Caring attitude” Planetree [25] “Care focused on the needs of individuals, guided by peoples’ preferences and values, and includes supporting structures, policies, and practices that create a culture of quality, compassion, and partnership across the continuum of care.” - “Partnership - Quality - Compassion” An essential component highlighted in the Planetree and Health Foundation frameworks is compassionate care, which has been described as a missing ingredient in care provision [25, 26, 33]. Compassion in healthcare is defined as empathetically understanding the patient’s distress and suffering, coupled with emotional resonance and effort to relieve it [34]. Another interesting central element outlined in the framework by the Centers for Medicare & Medicaid Services (CMS) is the measurement of care success through patient-reported outcomes (PROs), which are gathered directly from patients without any interpretation [22]. This approach allows healthcare systems to assess whether the services provided are truly aligned with patient-centered care. By comparing expected outcomes with actual patient experiences, and identifying gaps in care, PROs ensures that patient care is continually refined to meet the needs and preferences of patients, ultimately enhancing the quality of care delivered [35]. Importantly, the PCC is not limited to relationships between the physician and the patient but extends to interactive communication with nurses, staff, other healthcare provider, and family members or trusted friends, all as integral participants in the care process [22, 23, 25, 28, 30–32, 36, 37]. These diverse but interconnected elements frame PCC as a comprehensive, systemic approach. It incorporates individual autonomy, family involvement, and community participation, supported by an infrastructure of relational care, coordinated systems, and technological innovation, to meet the holistic needs of patients and populations. 3.2. Stakeholders’ Perspectives on PCC Implementation in Elderly Outpatient Settings Despite the heterogeneous landscape of patient-centeredness definitions, capturing the voices of elderly patients and healthcare providers/policymakers in our scoping review can provide valuable insights into how PCC is envisioned and should be put into practice. Both groups emphasized the importance of comprehensive care coordination [16, 29, 38–47] and individualized plans [16, 29, 40, 41, 44, 46, 48–50] to address the unique challenges of elderly outpatient care. Table 2 outlines the perspectives of stakeholders regarding the implementation of PCC in elderly outpatient settings. While it highlights the similarities and unique priorities identified by the two stakeholder groups, their specific focus areas reveal distinct priorities as well. Table 2 Perspectives of stakeholders on the implementation of PCC in outpatient settings for elderly patients. What does PCC in elderly outpatient settings mean for healthcare providers and policymakers? What does PCC mean for older adults in outpatient settings? Holistic/ whole person [29, 38, 41, 48, 51, 52] Preserved independence and control/ maintenance of independent activity of daily living [39–41, 43, 46, 47, 53] Care coordination [16, 29, 38–43] Feeling valued and respected/ dignity [39, 45–47] Multidisciplinary team-based care [16, 38–41, 51, 52] Seen as a meaningful human being [41, 47, 53] Interprofessional care [40, 42, 43] Holistic [46, 49, 54] Comprehensive care [38, 42] Continuous care/ consistency in care [46, 47, 49, 53, 54] Integrated care [40, 42, 52] Care coordination [39, 44–47] Individualized plan of care [16, 29, 40, 41] Multidisciplinary care [40, 44, 45, 49, 54] Patient’s goal and choice-oriented care [16, 29] Integrated care [45, 48, 54] Patient- (and family-) centered communication [38, 41, 52] Personal goal and choice-oriented care [43, 45, 48–50] Stimulating communication [39] Individualized plan of care [40, 44, 46, 48–50] Interactive communication [39] Being involved/ engaged [39, 43, 45, 46, 48, 54] Motivational interviewing [16] Easy access to care/ proximity [39, 44, 46, 47, 50, 53] Shared decision making [43, 48, 52] Knowing what comes next [39, 40] Patient engagement [43, 48, 52] Feeling informed [39, 44, 46, 47] Patient education and empowerment [43] Being educated [44–46, 48, 50] Compassion [39] Being empowered/ self-care [48] Sympathy [48] Patient activation [48] Empathy [41] Being centered at communication [46] Trustful relationship with staff [29] Feeling listened to/ open communication [43, 49, 50] Patient-centered blended eHealth applications [16, 40] Motivational interviewing [46] Accessible care [41] Feeling safe [47] Proactive [41] Trustful relationship with staff [39, 40, 46, 47, 49, 53] Compassion [50] For healthcare providers and policymakers, PCC was largely defined by a focus on delivering holistic [29, 38, 41, 48, 51, 52], integrated [40, 42, 52], and team-based care [16, 38–41, 51, 52]. They underscored elements such as interprofessional care [40, 42, 43], and comprehensive services [38, 42] to address the multifaceted needs of elderly patients, while fostering effective communication with patients and their families [38, 41, 52] through interactive [39], stimulating [39], and motivational approaches [16]. In addition, healthcare professionals believed addition of tele-heath applications could make a positive contribution to optimizing the care and encouraging patients [16, 40]. Elderly patients, on the other hand, viewed PCC through the lens of their lived experiences and personal priorities. Patients wanted to be empowered, have control on daily functioning and regain sense of control over their care, which they feel disempowered by their health conditions and perceived loss of identity [39–41, 43, 46, 47, 53]. This patient statement, “ I tried by myself for as long as I could until my self-esteem came back. So that I could shower myself, and that I decide for myself, that I’m not tied to someone else ”, clearly shows the importance of their need for a care that preserves their independence, autonomy and dignity [40]. They valued being recognized as meaningful individuals and emphasized the necessity for building real relationships with consistent staff, remembering them for more than just their illness [39, 40, 46, 47, 49, 53]. In addition, elderly patients stressed the importance of continuous and consistent care [46, 47, 49, 53, 54] and easy access to services [39, 44, 46, 47, 50, 53] that keeps them safe and engaged. Goal setting during shared decision making and knowing what comes next was also a recurring theme [39, 40]. 3.3. Barriers to Implementing PCC in Elderly Outpatient Settings Table 3 Identified barriers to implementing PCC in outpatient settings for elderly patients. Individual-level barriers Cost pressure [29, 44, 61] Transport challenges [40, 41, 50, 55, 57, 58] Explanations not tailored to patient knowledge-level [45] Language barriers [29, 53, 55, 56] Lack of conversation [46] Personnel or individual inattention [46] Technological challenges [40, 55, 57] Cognitive and physical restraints [41] Cultural barriers [29] System-level barriers Resource limitation/ insurance coverage [16, 29, 40–42, 49, 60] Lack of time [29, 40, 41, 46, 49, 51, 52, 55, 59, 61] Long waiting time and poor appointment scheduling [44–47, 50, 63] Organizational obstacles/ infrastructure/ hospital bureaucracy [41, 42, 49, 59] Insufficient staff/overburdened staff [16, 51, 55, 59, 61] Lack of role clarity [59, 62] Disconnections within healthcare systems, and between healthcare practitioners and care allies [55, 61] Inadequate reimbursement [41, 60] The need to go through several levels of care before receiving the right treatment [46, 61] Care fragmentation [46, 61] High turnover of healthcare professionals [47, 53] Space constraints [41, 55] Lack of leadership [42] High patient load [61] Healthcare workers with double positions [42] Lack of ownership by participants [54] Restricted opening time [46] Unclear care pathways and assessment methods [41, 51] Decreased time efficiency [62] Table 3 demonstrates barriers to implementing patient-centeredness within outpatient care delivery for older adults, categorized into individual-level and system-level challenges. Individual-level barriers largely involve factors affecting the interactions between patients and healthcare providers. Examples include staff inattention, lack of meaningful conversation and the use of overly technical medical terminology and language barriers [29, 45, 46, 53, 55, 56]. The presence of a family companion during consultations can minimize these issues by facilitating communication, improving the exchange of information, and helping clarify health-related instructions [56]. Language mismatches between patients and providers can further complicate the information exchange, causing confusion and a limited understanding of the patient’ needs and experiences throughout the care pathway [29, 53]. Transportation difficulties are also another significant individual-level barrier [40, 41, 50, 55, 57, 58], emphasize the need for co-located or conveniently accessible care facilities to enhance coordination and ensure care delivery as a cohesive unit. System-level barriers reflect structural and organizational obstacles that impede PCC implementation [41, 42, 49, 59]. Achieving PCC should be understood as a system-wide culture rather than merely a program embedded within ambulatory care practice and requires a financially sustainable reoriented care model [16, 60]. Securing adequate resources, particularly financial [16, 29, 40–42, 49, 60] and workforce-related support [16, 51, 55, 59, 61] represents as the most significant challenges in this level. Support from top leaderships within health systems, non-profit financial structures, private funding and expanded insurance coverage could allow for more flexibility in delivering care under this models. In addition, lack of strong leadership [42], staff shortages [16, 51, 55, 59, 61], healthcare providers with double positions [42], and high turnover rates among professionals [47, 53] can disrupt care continuity, hamper the development of meaningful provider-patient relationships and diminish patients’ sense of belonging. Organizing and addressing disconnections among care allies [55, 61], clarifying roles within multidisciplinary teams [59, 62], and streamlining care pathways [41, 51] can improve time efficiency and productivity, even without the need for a full redesign of the structural and organizational aspects of current care delivery models. Lastly, long waiting times and poor appointment scheduling [44–47, 50, 63] further limit the accessibility and continuity of care, presenting significant barriers in implementing PCC. 3.4. Practical Models of PCC and Patient-Centered Interventions in Elderly Outpatient Settings This section describes the various models of practical PCC delivery and interventions identified in the studies. These models, grounded in patient-centered principles, have been proposed and/or implemented as a solution to address mentioned gaps in care delivery, especially for older adults with multiple chronic conditions. We classified these models into three levels of care: primary health care, specialized care, or an integrated care, where specialized services are incorporated into the existing primary care framework. Table 4 provides a comprehensive overview of these strategies, detailing team composition, care attributes and services within the practice along with reported outcomes. The effectiveness of these models and interventions were evaluated using a ranges of outcomes, including patient-centered outcomes (e.g., care satisfaction and experience, quality of life, empowerment), clinical outcomes (e.g., disease management, symptom reduction, medication-related issues), and system-level outcomes (e.g., cost saving, reduced emergency department visits, hospitalizations). Table 4 PCC-affiliated models and interventions for older adults in the outpatient care practice. Primary Care Patient-Centered Models Model Team members Care attributes In-center services Out-of-center services Outcomes PCMH [64, 65] including its incorporation in Veterans Affairs through the Patient Aligned Care Teams (PACT) [69] and GeriPACT [70] • Physicians • Advanced practice nurses • Physician assistants • Behavioral health professionals • Nurses • Pharmacists • Nutritionists • SWs • Educators • Patient care coordinator • Enhanced accessibility as the initial point of contact with the healthcare system • Covering a broad range of individual healthcare needs • Multidisciplinary coordination and integrated care • Sustained partnership over time with patients • Continuous system-based approach for quality and safety improvement • Utilization of patient registries for population health management • Primary care • Mental health evaluation • Preventive care • Focused geriatric care and assessment in GeriPACT • Collaboration with community organizations and local support groups including home health care Reduced ED visits, positive effects on patient and staff experiences and no change in hospital admissions [71] With over three million member-month visits in nearly seven years of PCMH in Geisinger Health System: • Total 7.9% cost saving • Reduced acute inpatient costs [75] Different PCMH features affected expenditures in distinct ways. However, Even partial adoption of PCMH features helped practices improve healthcare quality while managing expenses [72]. With over 3 years of surveillance on centers implementing PACT and covering one million older adults: • No association between implementation progress index score and high cost healthcare expenditure [14] After one year of program implementation in Singapore: • Significant declined ED, PCP and specialist visits relative to comparison group • No change in hospitalizations [73] GeriPACT programs with mental and behavioral health provider in their team have higher success in management of psychological and cognitive conditions [74]. Comprehensive Primary Care (CPC) initiative [66] • Physicians • Nurse practitioners • Physician assistants • Patient care coordinators • Behavioral health professionals • Pharmacists • Risk stratification of patients • Coordinated team-based care management with involvement of patients/families • Electronic health record integration • Multi-payer payment structure • Continuous care along with advanced care accessibility • Comprehensive range of primary care • Preventive care • Care transition • Behavioral health integration • Electronic health record incentive programs In first two years of implementation at 500 primary care practices: • No significant change in mean monthly Medicare costs per beneficiary relative to comparison practices • Improved patient experience • Decreased PCP visits by 3% [76] Cumulative 4-year findings: • Significant improvement in care delivery based on practice survey particularly in its first 2 years of implementation • No significant changes in expenditure growth during CPC • Less growth in ED visits relative to comparison group • No significant difference in physician work satisfaction and burnout measures [77] Sage-atAge (Wijs Grijs) [120] • Geriatrician • Geriatric nurse • Pharmacist • Dental care worker • Proactive screening of care profile based on surveys and indicators • Referral of high risk and complex patients to the program • Comprehensive geriatric assessment by geriatrician or nurse • Shared decision making between care team and patients and consultation from out-of-center professionals if needed • Collaborating with primary physician and transfer of recommendations • Primary care • Social/psychological management strategies • Dental care • Medication management • Collaboration with PCPs • Referral to other professionals if needed Addition of motivational interviewing and goal setting in the framework of Sage-atAge + yielded no between group difference in well-being score. ProPCC Programme [108] • Geriatrician • Geriatric nurse • SW • Collaboration with primary care network • Weekly multidisciplinary meetings for case management • Biweekly meetings between the ProPCC team and other horizontal teams such as home service agencies and palliative care at home teams • Primary care • Transitional care • Social management strategies • Connection with community and social services With six month of implementation and covering 264 patients: • Significantly decreased ED visits, hospitalizations and days at hospital with shift to increased primary care visits • Increased days at home • Healthcare cost saving by 46.3% Senior Health and Wellness Center (SHWC) [60] • Geriatricians: 3 • Nurse practitioner • Nurses • SW • Dietician • Pharmacist • Receptionist • Initial health assessment and risk screening • Interdisciplinary primary care management of patients • Weekly team meeting: Chaplain, physical therapist, home health nurse, and behavioral health professional will join as well. • Patient case reviewed every three months • Long-term collaboration with community PCPs • Improvement of patient self-care • Primary care • Nutritional planning • Daily living activity evaluation • Falls/gait evaluation • Psychological and behavioral management strategies • Immunization • Physical therapy • Collaboration with community agencies and local support groups including Alzheimer’s Association and local Area Aging Agency and senior volunteers With 10667 visits and covering 1605 active patients in 3 years of implementation: • Higher employee satisfaction • Improved teamwork Taiwan Integrated Geriatric Care (TIGER) [121] • Physicians • Trained nurses • Pharmacist • Nutritionist • Recruitment of older adults with three chronic diseases • Implementation of twelve-month group-based multiple domain (physical activities, brain training and nutritional planning) intervention (similar to THISCE) integrated into primary care of patients and comprehensive geriatric assessment • Patient education • Primary care • Care management for multimorbidity • Patient education • Mental health • Phone reminders • Home assignments After one year of intervention implementation at 6 clinical sites: • Significantly higher average physical component scores relative to usual care group • Significantly higher mental component score at the end of follow-up • Reduced limited activities of daily living, slowness and overall pain Integrated Primary-Specialty Patient-Centered Models Model Team members Care attributes In-center services Out-of-center services Outcomes Chronic diseases Behavioral Health and Chronic Illness Care Intervention [90] • Physician • Nurses • Physician assistants • RN health coaches • Behavioral health triage therapists • Panel managers • Practice managers • Behavioral health screening at triage • Multidisciplinary case management and shared decision making based on guidelines • Self-management training • Primary care • Behavioral/psychological health screening and management strategies • Care management for HF, DM, HTN, obesity and asthma • Self-care educations • Electronic patient portal • Connection to community resources From year two of implementation onward in 22 practice centers: • Increased recommended diabetes care acceptance • Decreased ED visits by 4.9% relative to comparison group • No change in Medicare expenditure and hospitalizations Patient-Centred Team Intervention [109] • Physician • Geriatric nurses • Physician assistants • Nurse coordinators • Occupational therapist • Physiotherapist • Pharmacist • Proactive selection of high cost high complexity patients • Comprehensive geriatric evaluation • Complex patient issues addressed by a multidisciplinary geriatric team together with the patient • Continuous care process and adjustment based on patient feedbacks • Primary care • Secondary care During six months of implementation and including 439 multimorbid elderly patients: • Reduced use of ED, bed days and re-admission • Substantially reduced mortality rate • Increased outpatient visits Local, collaborative, stepped and personalized care management for older people with Chronic diseases (LoChro-Care) [122] • Nurse specialized in health education • SW • Recruitment of multimorbid older adults and initial comprehensive assessment by chronic case manager (nurse or SW) • Personalized care navigation through interaction with patients • Multidisciplinary geriatric team meeting every two months or in the case of urgent need • Care continuity in period of a twelve months program and collaboration with PCPs • Primary care • Assessment of activity of daily living, mobility and mood/cognition • Medication management • Patient education • Link to local geriatric support services With 12 months of intervention implementation in ~ 250 patients: • No significant between-group difference in physical, psychological and social composite scores compared to usual care group with both groups experiencing decline in their composite scores • No significant between-group difference in care satisfaction [123] Post-discharge transitional care Transitional Care Manager [82] into PCMH • Physician • Nurses • Specialists • Health educator • Pharmacist • Proactively referred patients from PCPs • Patient guideline based risk stratification • Shared multidisciplinary team problem-solving with patient/family and continuity of monitoring • Patient education • Nutritional planning • Medication review • Medical management Preliminary enrollment of 50 patients over 6 months, showed: • Declined ED visits and hospitalizations • Improved patient care experience and resource saving Person-Centered Lifestyle Change Intervention Model [124] • Specialized nurses • Other patients • Invitation of older adult patient hospitalized during the last months to practice groups with other patients and nurses • Self-management and stress assessment at beginning and every 4 weeks during a 6–8 months program • Active participation of patient and education programs • Psychological/emotional and social management strategies • Patient empowerment program and education • Peer groups • Relaxation exercises • Lifestyle coaching Transitional Care Stroke Intervention [107] • RNs • Occupational therapist • Physical therapist • SW • SLP • Patient care coordinator • Designated for older adult with stroke discharged from hospital • Usual outpatient rehabilitation services for stroke plus six months of virtual coordinated interprofessional care delivery • Monthly team consensus meeting • Medical management • Medication reconciliation • Preventive care • Psychological/social management strategies • Patient empowerment • Online resources for patient empowerment • Phone/video visits In 6 months of intervention implementation for 44 patients: • No significant change compared to usual group in readmission risk • Improved physical functioning, self-management and patient care experience without increasing total healthcare expenditure Dementia and memory Integrated Memory Care Clinic [85] into PCMH • Specialized APRNs • RNs • SW • Patient care coordinators • Geriatric psychiatrist • Licensed counselor • Psychiatric home health providers • Pharmacist • First-line APRN evaluation of referred patients diagnosed with MCI or dementia • APRN collaboration and consultation with neurologist, geriatric or other specialties • Structured team meetings • Shared decision making and determining care goals • Scheduled appointments for care continuity • Available on-call APRN contact for inquiries • Accountability for simultaneous primary care management • Primary care • Dementia medical management • Psychological and emotional evaluation every 6 months • Annual cognitive testing • Social management strategies • Community collaboration with support groups including Area Agencies on Aging, Alzheimer’s Association and in-house support services In 1 year of implementation and caring for 139 patients: • Reduced monthly ambulatory-sensitive hospital admissions (6.7–0.8%) in the second of year • No significant improvement in neuropsychiatric symptom severity • Increased involvement in community-based services [85] Within 9 months of implementation: • Decreased symptom severity of patient • Decreased caregivers distress [86] With one year of care delivery: • Sense of belonging in caregivers [87] Specialized Senior Clinic [101] • Geriatrician • Geriatric psychiatrist • Occupational therapist • Physiotherapist • SW • Patient care coordinator • RN • Pharmacist • Dietician • Clerk • Screening and triage of PCP referred patients with memory/cognition change by patient care coordinator • Comprehensive geriatric evaluation and interprofessional health planning with client/family • Follow-up with the clinic as required • Long-term collaboration with community PCPs • Patient self-management programs • Dementia medical management • Nutritional planning • Physical therapy • Occupational therapy • Collaboration with community agencies including Alzheimer Society and in-house support services In one year of implementation and with ~ 19000 visits: • High level of satisfaction with the care model among both patients and care team Fracture Fracture Liaison Service (FLS) into PCMH [88, 89] • Primary care physician • Orthopedic surgeon • Physician assistant • Clinical pharmacist practitioner • Patient care coordinator • Nurse practitioner • Proactive selection of patients with fragility fracture • Appropriate testing and treatment • Coordinated care with PCPs • Long-term care partnership • Transitional care • Primary care • Medical management • Preventive care • Patient education Kidney diseases PCMH for Kidney Diseases (PCMH-KD) [84] • Nephrologist • Dialysis nurse • Primary care physician • Nurse coordinator • Community health worker • Dietician • SW • Pharmacist • Initial assessment by internist and primary care provision within the framework of dialysis care • Weekly comprehensive, multidisciplinary team care management directed by patients’ needs • Regular continued hemodialysis in dialysis unit • Monthly consensus meeting • Medical management • Primary care • Hemodialysis • Nutritional planning • Patient education • Medication review • Link to community resources With 18 months of implementation and covering 175 patients: • Decreased ED visits and admissions • Improved life quality of patients [110] Population Health Value - Chronic Kidney Disease (PHV-CKD) initiative [83] • Nephrologist • Interventional radiologist • Primary care physician • Patient care coordinators • SW • Pharmacist • RN • Nurse case manager • Proactive selection of high risk complex CKD 4–5 patient • Initial assessment and risk stratification • Coordinated care by a multidisciplinary, interprofessional team through patient-centered communication • Establishment of an aligned system-wide care pathway • Primary care • Preventive care • CKD management • Social/behavioral management strategies • Collaboration with community resources • Available telephone contact with RN/SW for questions Following one year of initiative implementation and covering ~ 1450 patients: • Reduced monthly hospital admissions by 3.4% and ED visits by 2.6% relative to pre-implementation Medication reconciliation and polypharmacy Medication Management Program [102] into PCMH • Pharmacist • Pharmacist embedded in PCMH core team • Secondary referred from other team members or if the patient had asked • Coordinated medication adjustment and counseling • Management of medication-related issues • Online messaging or phone encounters By enrolling ~ 280 patients in the initiative: • Significant decrease in hospital admissions relative to • Increase in physician office visits Low back pain Collaborative Care for Older Adults [125] • Family medicine physician • Chiropractor • Inclusion of older adults with moderate severity subacute/chronic low back pain • Focused evaluation of patient and development of individualized medical management and referrals if needed • 12 weeks of individualized chiropractic care including mobilization and manipulative therapies and exercises (Dual Care) • Enhanced interdisciplinary and collaborative care for those receiving Shared Care • Chiropractic services • Medical management • In-home exercises With twelve weeks of trial initiation: • Both usual care group and intervention groups experienced improvement in their pain intensity and disability score but no significant between-group differences noted • Higher care satisfaction, quality of life and perceived improvement in intervention groups [15] Fall Fall Prevention Initiative [58] into Annual Wellness Visits • RNs • Identification of at-risk patient with targeted questions, tests and home safety checklist • Development of individualized plan of care, referrals, referral, assistive equipment and home safety interventions as needed based on guidelines and patient preferences • 2 week follow up to evaluate patient adherence and potential barriers to plan • Primary and preventive care • Patient education • Home safety assessment Out of 522 patients in Annual Wellness Visits, 21% screened positive for elevated fall risk with 74% willing to receive personalized care strategy. Follow-up call showed 74% adherence for gait/strength/balance interventions and 67% adherence for home safety interventions. Strategies to Reduce Injuries and Develop Confidence in Elders (STRIDE) [100] • Trained nurses • Identification of high fall risk patients with targeted questions • Comprehensive risk stratification by evaluation of gait/balance/strength, vision, home safety, osteoporosis and vitamin D • Development of individualized care strategy and referrals if needed • Follow-up and annual risk reassessment • Primary and preventive care • Patient education • Access to community resources including exercise programs Intervention being implemented in 86 primary care practices showed: • No significant difference in serious fall injury events per 100 person-years in intervention group Frailty Frailty Screening and Geriatric Assessment Service in outpatient nephrology center [126] • Physician • Occupational therapist • Dialysis staff • Clinical nurse specialist • Dietician • Psychologist • SW • Frailty, psychological and functional screening of nephrology patients using standard tools • Comprehensive geriatric assessment by occupational therapist • Multidisciplinary team meeting to implement care plan based on patient’s need • Medical management • Dialysis • Preventive care • Nutritional planning • Medication management • Social and psychological management strategies Of 450 patients in nephrology center, 33% screened positive for frail with 35 patients receiving comprehensive geriatric assessment and multidisciplinary planning. Condition-Specific Patient-Centered Specialty Clinics Model Team members Care attributes In-center services Out-of-center services Outcomes Dementia and memory Comprehensive Memory Center [62] • Behavioral neurologist: 1 • General neurologist: 1 • Geriatric psychiatrist: 1 • Neuropsychologist: 2 • Advanced nurse practitioner: 1 • RN: 1 • SW: 3 • Speech language pathologist (SLP): 1 • Medical assistant: 1 • Pharmacist: 1 • Psychometrist: 2 • Initial assessment and diagnostic evaluation by physician/neuropsychologist, APN and SW • Onsite diagnostic facilities • Co-located visits of multiple specialties • Bi-weekly interprofessional joint visits throughout the care • Weekly consensus meetings of healthcare team for care plan decision • Discussion about care plan with patient/carer dyad during feedback appointment • Post-diagnosis support visits for care continuity • Medical management • Psychological evaluation • Social/behavioral management strategies • In-home support: counselling by SW, cognitive communication therapy by SLP and in-home coordination of care • Community collaboration with local support groups and agencies In 3.5 years of implementation and caring for ~ 750 patients: • Reduced initial visit to diagnosis interval • Patient/carer dyad satisfied by the model • Improved effective interprofessional team dynamics [62] Multidimensional Interdisciplinary Rehabilitation in Dementia (MIDRED) [127] • Neuropsychologists • Physicians • Nurses • Physical therapist • Occupational therapist • Dietician • SW • Pharmacist • Dental hygienist • Initial comprehensive assessment of dementia confirmed patient • Multidisciplinary individualized rehabilitation goal setting according to patient’s problems and needs • Rehabilitation program for sixteen weeks • Caregiver group education and discussion • Rehabilitation • Caregiver education • Link to community services With 4–5 months of intervention implementation and inclusion of 16 patients, they felt empowered and seen, gained new insights and incentives, and experienced togetherness. Rheumatology Lifelong Treatment Model for Rheumatoid Arthritis [128] • Rheumatologist • Nurse • Physiotherapist • Occupational therapeutic • Pharmacist • Rheumatologist visit of referred patient with undiagnosed symptoms from PCP • Shared decision making and multidisciplinary patient-centered treatment until remission • Patient empowerment and self-monitoring program • Health maintenance through PCP and tele-health monitored by rheumatology-specialized nurses • Medical management • Patient empowerment and self-monitoring program • Tele-Health Cancer Prostate Cancer Unit [80] • Clinical director • Uropathologist:1–2 • Urologist: ≥ 2 • Radiation oncologist: ≥ 2 • Medical oncologist: ≥ 1 • Nurse specialist: ≥ 1 • Data managers • Documentation specialist • Recruiting individuals with prostate cancer in all stages • Ideally co-located buildings • Protocol-based single multidisciplinary team care and regular follow up • Collaboration with out-side adjuvant and palliative therapies under its direction • Rehabilitation under its direction • Minimum annual audit meeting for evaluation of quality indicators and protocols • Medical management • Observational strategies • Chemotherapy • Hormonal therapy • Radiation therapy and brachytherapy • Surgery • Access to different professional services including radiologist, medical physicist, physiotherapist, sexologist, adjunctive, palliative and psychological therapies • Collaboration with advocacy group associations such as Europa Uomo Oncology care with integrated supportive team based on PACT model [57] • Attending medical oncologists • Medical oncology fellows • Psychology interns • Palliative care physician • Oncology nursing staff • Patient care coordinator • SW • Clinic clerks • Screening and risk stratification of newly diagnosed patients at beginning and every three months or with change of disease course via distress tools • Multidisciplinary problem solving according to patient’s preferences and referrals to corresponding specialists or supportive care services • Patient education • Oncology care • Psychological management strategies • Palliative care • Adjacent same-personnel chemo-infusion clinic • Access to support services including in-home services, dietician, physical and occupational therapist and mental health programs • Partnership to local support groups including Gilda’s Club and the Cancer Support Center Over two years and half of program initiation and ~ 1000 screenings occurred, followed by corresponding care process. Psychiatry Enhancing Quality in Psychiatry with Psychiatrists (EQUIPP) [129] • Psychiatrist • Clinical pharmacist • Comprehensive medication assessment and review of medication-related issues by pharmacist • Development of care plan according to patient’s preferences and collaboration with physician • Patient/carer education • Care surveillance and medication evaluation by pharmacist for six months • Medication management • Follow-up by phone Within six months of implementation and inclusion of 26 patients: • No change in the total number of medication related issues • No difference in healthcare utilization or transfers to higher care levels A) Primary Healthcare Models Primary healthcare models focus on delivering comprehensive and coordinated services at the first point of contact, aiming to address the general health needs of older adults while integrating behavioral health, chronic disease management, and preventive care. Notable models in this category include PCMH [64, 65], Comprehensive Primary Care (CPC) initiative [66], and Guided Care [67]. Among these, PCMH stands out as a widely adopted model in the US, implemented in over 10,000 primary care practices by more than 50,000 clinicians, adhering to standards set by the National Committee for Quality Assurance (NCQA) [68]. This model emphasizes a holistic, team-based approach that manages patients' health needs, delivers accessible services, enhances quality & safety, and redesigns traditional care structures. Its interdisciplinary teams typically include physicians, nurses, behavioral health professionals, case managers, pharmacists, social workers, and nutritionists [65]. The US Department of Veterans Affairs introduced the Patient-Aligned Care Team (PACT) in 2010, followed by the GeriPACT model specifically for older veterans, as extensions of the PCMH framework [69, 70]. The adaptation of PCMH and PACT for elderly outpatient care has demonstrated significant benefits, including improved care quality, reduced emergency department visits, and more efficient care delivery [71–74]. However, studies show mixed results regarding their impact on healthcare expenditures, with some reporting cost savings [75] and others finding no significant change [14, 72]. Building on PCMH principles, the CPC initiative and its successor, CPC Plus (CPC+), were introduced by the Centers for Medicare & Medicaid Services (CMS) to incorporate multi-payer payment reform and data-driven interventions. Over four years, CPC achieved improvements in care delivery, slower growth in ED visits, and better patient experiences, although it did not significantly reduce healthcare utilization [76, 77]. Similarly, CPC + demonstrated reduced ED visits from the first year onward and decreased hospital admissions in later years, but with no discernible change in total expenditures over five years [78]. B) Specialized Healthcare Models Specialized care models, on the other hand, provide care for specific conditions, often involving multidisciplinary teams with expertise tailored to a particular disease or health issue while managing physical, emotional or psychological issues arising from the disease. PCC-aligned specialty units such as Prostate Cancer Unit and Breast Cancer Model have shown success in structuring cancer care across the patient journey and improve care coordination [79–81]. Similarly, Comprehensive Memory Center, which provide focused and specialized services to patients living with dementia, also has demonstrated promising results in improving disease diagnosis and care satisfaction, and strengthening interprofessional teamwork dynamics [62]. C) Integrated Healthcare Models Lastly, integrated care models expand on primary care frameworks by incorporating specialized services tailored to the needs of a targeted populations, and aim to enhance care continuity and outcomes. Transitional care programs integrated into primary care, such as the Transitional Care Manager embedded within the PCMH, have demonstrated notable benefits. Over six months of this integration, it resulted in resource savings, fewer ED visits, and hospitalizations, alongside improved patient experiences [82]. Likewise, integrated models such as PCMH-KD and Population Health Value - Chronic Kidney Disease (PHV-CKD), designed for patients with end-stage renal disease, reported reductions in ED visits and hospital admissions [83, 84]. Integrated Memory Care Clinic, as another integrated model of care tailored for patients with mild cognitive impairment or dementia, combined primary care with specialized dementia management. This model achieved promising outcomes, including reduced ambulatory-sensitive hospital admissions, decreased symptom severity, and alleviated caregiver distress [85, 86]. Caregivers also valued the dedication of staff and access to after-hours services, which enhanced overall satisfaction with care [87]. Other integrated programs address gaps in follow-up care and compliance among vulnerable populations. For example, older adults with osteoporotic fractures often exhibit poor follow-up, but integrating a Fracture Liaison Service within PCMH frameworks has shown potential for addressing these challenges effectively [88, 89]. Furthermore, interventions like the Behavioral Health and Chronic Illness Care model, targeting primary care and selected chronic conditions, have also demonstrated strong positive effects, such as improved acceptance of care and reduced ED visits, though without significant changes in Medicare expenditures [90]. 4. Discussion We aimed to explore how PCC is conceptualized and implemented in elderly outpatient setting. By systematically mapping the diverse dimensions of PCC, identifying stakeholder viewpoints, examining barriers to its adoption, and assessing the structure, processes, and outcomes of various practical PCC models, our study contributes to understanding how PCC can be integrated into existing healthcare systems, especially in resource-constrained settings. “Nothing about me without me , ” a phrase by Valerie Billingham, captures one of the most resonant principles of partnering with patients in their care plans [91]. This statement aligns deeply with PCC concept and emphasizes transforming patients from passive recipients into active participants. Shared decision-making, referred to as the “pinnacle” of PCC [92], encourages healthcare providers to step back from their paternalistic, directive role and adopt a partnership-based approach. By asking not just “What is the matter?” but also “What matters to you?” providers call for a care dynamic grounded in respect for the patient’s values, needs and preferences, while also sharing responsibility for outcomes and experiences throughout the care continuum [4, 36, 92]. From the studies reviewed, it became evident that PCC delivery, particularly for older adults, is not merely a clinical framework but a culture that needs to be cultivated system-wide. From the patient’s first interaction with the healthcare system to follow-ups and feedback mechanisms, every touchpoint is an opportunity to embody PCC principles. This includes the center organizational structure, attitudes of healthcare providers and staff, care plan development processes, care pathways, community collaborations and local support groups, payment structures and program evaluations [1, 16, 25, 28, 29, 37, 77]. Understanding and bridging the perspectives of patients and providers is central to the successful implementation of PCC. Our scoping review showed that although patients and providers shared the common goal of achieving high-quality, personalized care plans, their perspectives on what PCC looks like differed in emphasis. Providers tended to focus on systemic efficiency, teamwork, and care coordination [16, 38–43, 51, 52], while patients prioritized accessibility, emotional connection, trust, and the relational aspects of care delivery [39, 40, 43, 44, 46, 47, 49, 50, 53]. Effective PCC must go beyond addressing medical conditions; it requires healthcare providers to see the person beyond their diagnosis, understand their life beyond hospital walls and incorporate life stories into care plan development [41, 47, 53]. Patient experience emerges as a critical measure to of PCC and should be continuously monitored to shape care trajectory. For older adults, care is rarely a solitary endeavor. They often involve family members or trusted friends in medical decision-making and health management [56]. This partnership underscores the importance of integrating not only the patient’s but also their support network’s perspectives into the care process [28]. Patient and Family Advisory Councils, which includes patients and families, directors, healthcare providers and staff, can facilitate this integration and co-create care models tailored to elderly unique values and preferences [93]. The implementation of PCC faces significant barriers, particularly in resource-constrained settings. From our review, the most frequently reported challenges included infrastructural obstacles, financial and human resource limitations, transportation barriers and lack of time [16, 29, 40–42, 46, 49–52, 55, 57–61]. Addressing these barriers requires a multi-faceted approach, combining leadership support, financial innovation and strategic policy changes. Strong commitment from top leadership within health systems is pivotal in driving the cultural and structural transformation necessary for PCC [94]. Leaders can champion PCC by aligning organizational priorities, providing clear mandates for PCC implementation, being open to new ideas, forming dedicated PCC committees and allocating dedicated resources [95]. Leadership training and accreditation programs, such as those offered by NCQA, can also incentivize widespread adoptation of PCC practices [95]. Financially, incorporating non-profit structures [16] and securing private funding such as through philanthropic investments [96] can provide supplementary resources for launching PCC programs. Expanded insurance coverage and integration into value-based reimbursement systems represent strategic policies to overcome financial barriers [97, 98]. In addition, training healthcare providers on PCC principles has shown to improve adherence to patient-centered practices and enhance care satisfaction [99]. The finding from our scoping review highlighted several practical PCC-aligned models delivering care to elderly patients in outpatient settings. Successful models consistently included multidisciplinary teams, holistic and comprehensive care pathways, active patient engagement mechanisms and robust care coordination and continuity. Majority of models involved collaborations with community-based agencies and social services, which added significant value to patient care delivery [57, 62, 65, 80, 83, 85, 100, 101]. Clinical pharmacist and social workers were often included in the healthcare team. Pharmacists had an integral role in medication reconciliation, addressing medication-related issues, recommending appropriate medications alternatives, and managing polypharmacy [65, 102]. Social workers, also, supported four domains of care: behavioral health management, acting as a case managers, discussing financial challenges and potential barriers to care, and facilitating access to community services [62, 65, 103]. Care coordinators, often as a core team member, played an integral role in improving patients’ outcomes by enhancing interdisciplinary communication, managing care continuity, and optimizing resource use. Nurses, occupational therapists, and social workers frequently functioned as care coordinators in different models of PCC implementation. Moreover, studies have shown that nurses, as primary points of contact with patients, play a central role in implementation of PCC culture. Aside from nurses’ contribution to patient triage, comprehensive geriatric assessments, screening, education and coaching, care coordination, nursing services and referrals, nurse-led PCC models have demonstrated notable success in improving patient adherence, clinical outcomes, and care quality [104–106]. These models collectively demonstrate the potential of PCC interventions to enhance care quality, optimize outcomes, and address systemic challenges in elderly outpatient settings. While cost-effectiveness remains variable, the overall improvements in quality of life and patient satisfaction highlight the value of incorporating PCC into healthcare delivery. The evidence suggests that, when implemented correctly, PCC interventions can enhance outcomes without imposing significant additional healthcare expenses [14, 72, 76, 90, 107], or even yielding savings by reducing unnecessary hospitalizations or emergency visits [75, 82, 83, 108–110]. Recommendations for implementing PCC in LMICs Based on insights from PCC concept in elderly outpatient care context, stakeholder viewpoints, identified barriers to the operationalization of PCC at practical levels, and health administration and community medicine experts’ opinions, we developed a PCC framework and provide actionable recommendations for enhancing elderly outpatient care services in LMICs. In LMICs like Iran, healthcare systems face significant challenges related to organizational infrastructure, payment structures, financial constraints, fragmented health insurance and information technologies [111]. As identified by our scoping review, these barriers hinder the widespread adoption of PCC. Despite the Ministry of Health's incorporation of hospital accreditation processes since 2012, PCC lacks a clearly defined position in these policies. Additionally, no accreditation standards exist for outpatient clinics or non-surgical centers, with current guidelines only evaluating hospital outpatient departments [112, 113]. Furthermore, clinic visits typically structured as single-physician encounters with little integration of allied health professionals, medical decision dominance by physicians, and an average visit length of less than five minutes in Iran leave no place for actual patient-centeredness [111, 114, 115]. Given these challenges, we propose that the initial implementation of PCC in Iran should focus on older adults with multimorbidity, who are likely to benefit the most. Multimorbidity is a growing issue in Iran, with conditions such as ischemic heart diseases, stroke, low back pain, neoplasms, and diabetes mellitus being the top five causes of disability-adjusted life years in older population of Iran [116]. Focusing on this population allows for a targeted approach, addressing the most pressing health issues while avoiding the complexities associated with providing universal care across all age groups. Our seven-dimensional PCC model for elderly outpatient care delivery aligns with global principles of PCC while tailoring its implementation to the Iranian context [Figure 2]. The seven dimensions are: Access to Care: Ensuring that care is physically and temporally accessible to patients. Proactive Care: Actively identifying and engaging eligible patients through healthcare systems, such as hospitals or primary care providers rather than waiting for patients to initiate contact. Patient Empowerment: Educating patients to have patient-controlled care and patient-monitored care. Integrated into Care Pathway: Providing specialized care services for select conditions within primary care framework. Whole-Person Approach: Addressing the full range of a patient’s context, including physical, mental, social and financial aspects. Coordinated Care: Promoting teamwork among healthcare providers and other healthcare centers to deliver comprehensive care. Shared Decision-Making: Partnering with patients in decisions about their treatment, respecting their preferences and values, and sharing responsibility. For the initial phase of implementation in Iran, we propose an integrated healthcare model focusing on the elderly population with two or more of select guideline-based confirmed conditions: ischemic heart diseases, stroke, subacute/chronic low back pain, neoplasms, and diabetes mellitus. This model should blend primary and specialized care, using principles from successful models like the PCMH [65] and Behavioral Health and Chronic Illness Care Intervention [90]. By adapting these models, we can provide holistic care that integrates physical health, mental health, and social support. Our proposed interdisciplinary team for PCC implementation includes internist, nurses, physical therapist, social worker, occupational therapist, clinical psychologist, dietician, clinical pharmacist, and receptionist/medical informatics. The role of the patient care coordinator and educator is critical, and this responsibility should be assigned to nurses. Nurses are well-positioned to provide comprehensive care, educate patients and their families, and ensure care continuity. This model should offer a comprehensive range of services, including preventive care, chronic disease management, medication management, psychological support, social/behavioral health management, frailty and fall risk assessments, physical activity counseling, and nutritional planning. Conclusions and Recommendations The integration of comprehensive, preventive and PCC has the potential to enhance both the quality of care and patient satisfaction. To support PCC adoption in Iran and similar LMICs, we recommend: Assessing the cost-effectiveness of the proposed PCC model in LMICs. Launching financially sustainable pilot programs focused on older adults with multimorbidity. Designing training programs for healthcare providers on PCC principles and practices. Establishing policy and accreditation frameworks that incentivize PCC adoption and ensure periodic reevaluation Abbreviations CMS Centers for Medicare & Medicaid Services CPC Comprehensive primary care JBI Joanna Briggs Institute LMIC: Low- and middle-income countries NCQA National Committee for Quality Assurance PACT Patient-aligned care team PCC Patient-centered care PCMH Patient-centered medical home PRISMA-ScR Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews PRO Patient-reported outcome Declarations Ethics Approval and Consent to Participate: Not applicable. Consent for Publication: Not applicable. Competing Interests: Authors declare no competing interests. Funding: No funding was received for this study. Author Contribution NH, MA, and Ehsan T conceptualized the study and contributed to the design of methodology. Erfan T, AA, and FG were responsible for screening and data extraction. SB and Ehsan T presented and contributed to data interpretation. Erfan T, AA, FG and SB drafted the manuscript. MA and Ehsan T supervised the overall project. All authors critically reviewed and approved the final manuscript. Acknowledgements: None. Data Availability Data is provided within the manuscript or supplementary information files. References Tinetti, M.E., A.D. Naik, and J.A. Dodson, Moving From Disease-Centered to Patient Goals-Directed Care for Patients With Multiple Chronic Conditions: Patient Value-Based Care. JAMA Cardiol, 2016. 1 (1): p. 9–10. Rygiel, K., A transition from disease-centred to goal-directed individualised care of patients with multiple morbidities: a journey to goal-orientated patient healthcare. INNOVATIONS, 2018. America, C.o.Q.o.H.C.i., Crossing the quality chasm: a new health system for the 21st century . 2001: National Academies Press. Epstein, R.M. and R.L. Street, Jr., The values and value of patient-centered care. 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Taherifard","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA50lEQVRIiWNgGAWjYBAC+wYGNiAlwcDG3n7wAZDFw0dIiwEbVAsfz5lkA5AWNiK1MDDISSSYSYAYhLXINz978HGPRTQbQ0Ja5dccOxk2BuaHj27g8wsbm7nhjGcSuW0MB4/dlt2WDHQYm7FxDn6HmUnzHABqYWxIuy25jRmohYdNGr8W9m/Sf0BamBnMiiW31ROjhcdMmgGkBWgd48dth4nRklMm2QPSwsOTLM247TgPGzMBv9g3H98m8eNAXe78+c8Pfvy5rdqen7354WN8WlAAMw+YJFY5CDD+IEX1KBgFo2AUjBgAAEFEQAqVXIjlAAAAAElFTkSuQmCC","orcid":"","institution":"Shiraz University of Medical Sciences","correspondingAuthor":true,"prefix":"","firstName":"Ehsan","middleName":"","lastName":"Taherifard","suffix":""}],"badges":[],"createdAt":"2025-01-22 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10:56:42","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":325934,"visible":true,"origin":"","legend":"\u003cp\u003eFramework for creating a PCC environment in elderly outpatient settings\u003c/p\u003e","description":"","filename":"Figure2.jpg","url":"https://assets-eu.researchsquare.com/files/rs-5882301/v1/e237b0a31457b8c12033016f.jpg"},{"id":96651082,"identity":"ed086ed3-fea1-44da-b272-a24a7e40f46d","added_by":"auto","created_at":"2025-11-24 16:13:45","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":2484665,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-5882301/v1/19e3c437-cb1a-4f67-b18b-48f92a1cc745.pdf"},{"id":79833311,"identity":"e33037d4-1afc-4c14-b10b-e79b23556483","added_by":"auto","created_at":"2025-04-03 10:56:43","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"supplement","size":565136,"visible":true,"origin":"","legend":"","description":"","filename":"SupplementaryMaterial.pdf","url":"https://assets-eu.researchsquare.com/files/rs-5882301/v1/8845c4c9ec02c051127b97db.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Exploring patient-centered care delivery in elderly outpatient settings: A scoping review and recommendations for implementation in countries with low and middle income","fulltext":[{"header":"1. Background","content":"\u003cp\u003eThe shift from disease-centered to patient-centered care (PCC) has become essential in advancing healthcare services and patient outcomes, especially in the context of multiple chronic diseases [1, 2]. Identified as one of six core elements in the healthcare quality framework by the Institute of Medicine, PCC highlights the need to customize care navigation to the unique needs, preferences, and values of individual patients, encouraging collaboration with healthcare providers as equal partners toward shared goals [3, 4]. In the past decade, it has gained greater importance in elderly care due to the aging population and the increasing prevalence of chronic conditions that require continuous, patient-centered interventions [5, 6]. Older adults in outpatient settings often face unique challenges, including the need for managing multimorbidity, polypharmacy, and functional limitations [7]. Based on the World Population Prospects 2022, the population of adults aged 65 and above has been projected to increase globally from 10% in 2022 to 16% by 2050 [8]. In United States (US), despite being the smallest age group population, they account for approximately 37% of total healthcare spending [9]. In addition, this population attend ambulatory care visits nearly twice as often as younger individuals, representing 26% of all physician office visits and 34% of prescription medication usage [10\u0026ndash;12]. Traditional healthcare models, often designed for acute, episodic care, may not adequately meet the ongoing needs of this population. This calls for a more coordinated approach to healthcare delivery [6].\u003c/p\u003e \u003cp\u003ePCC seeks to improve not only clinical outcomes but also patient satisfaction, empowerment and the overall healthcare experiences, particularly in outpatient settings where long-term management and patient involvement are critical [4, 13]. However, previous studies have shown inconsistent findings regarding better clinical outcomes and cost savings in this population after implementing patient-centered initiatives. For instance, in a longitudinal study of over one million patients aged 65 years and older, improvement or decline in patient-centered medical home (PCMH) implementation showed no significant change in the use of high-cost healthcare services among patients at each clinic site [14]. In another patient-centered practice model for low back pain in community-dwelling elderly patients, interprofessional practices over one year of trial showed no between-group differences in pain intensity and related disability score, compared to usual care [15]. These findings suggest that while PCC has many theoretical benefits, practical implementation may yield variable outcomes depending on context and model framework.\u003c/p\u003e \u003cp\u003eA sharper definition of PCC and its dimensions is critical for efficiently incorporating this concept into healthcare systems. Reviewing previous literature demonstrates that different healthcare organizations often operationalize PCC in diverse ways, with some incorporating only selected domains of PCC or single patient-centered interventions into their existing care, leading to inconsistent practices and outcomes across settings [6, 16]. This scoping review aimed to explore existing evidence on PCC for elderly patients in outpatient settings to provide a comprehensive overview of PCC definitions, key elements, and perspectives from policymakers, healthcare providers, and patients/caregivers. It also mapped common barriers to implementing PCC models and the effectiveness of various PCC adoptations and interventions for elderly care. Additionally, given the considerable limitations in delivering patient-centered care to elderly outpatients in LMICs, this review provided recommendations for integrating PCC into their healthcare systems to enhance care quality for the aging population.\u003c/p\u003e"},{"header":"2. Methods","content":"\u003cp\u003e A scoping review approach was chosen over a systematic review because it allows for a comprehensive and structured mapping of the current body of literature, which is crucial for addressing our broad objectives in examining various aspects of PCC for elderly patients in outpatient settings [17]. This scoping review followed the Joanna Briggs Institute (JBI) methodology for scoping reviews [17]. Our review is reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) 2018 statement [18]. No protocol for this review has been published or registered.\u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003e2.1. Review Questions\u003c/h2\u003e \u003cp\u003e \u003col\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eHow is PCC defined in the context of elderly outpatient healthcare?\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eWhat are the common elements of PCC models in elderly outpatient care?\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eWhat perspectives do key stakeholders (patients/caregivers, healthcare providers, and policymakers) hold on the implementation of PCC in outpatient settings for elderly patients?\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eWhat are the barriers to implementing PCC in outpatient settings for the elderly?\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eWhat are the practical models of PCC adoptation or patient-centered interventions incorporated into existing care pathways for older adults in outpatient centers?\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eWhat are the reported outcomes associated with PCC models or interventions in elderly outpatient settings?\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003c/ol\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003e2.2. Inclusion and Exclusion Criteria\u003c/h2\u003e \u003cp\u003eWe used the Population, Concept, and Context framework, recommended by JBI to identify eligible sources of evidence:\u003c/p\u003e \u003cp\u003e\u003cul\u003e\u003cli\u003e\u003cp\u003ePopulation: Adults aged 65 and above. We also included studies that mean or median age of study participants is \u0026ge;\u0026thinsp;65 years. Studies with mixed-age populations were excluded unless they provided separate or generalizable findings specific to older adults.\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eConcept: The review aimed to explore the delivery and components of PCC. This included definitions of PCC, core elements, perspectives from patients, healthcare providers, and policymakers, as well as barriers to and outcomes of PCC implementation. In addition, we included studies assessing patient-centered interventions integrated into existing care pathways in the review. Studies focusing solely disease-specific interventions without a broader PCC concept were excluded.\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eContext: Outpatient healthcare settings providing long-term chronic care delivery and can be from primary care offices, day care hospitals, specialty clinics, rehabilitation and therapy centers, dialysis centers. Institutions/ centers focusing end stage and palliative care, urgent care centers such as retail clinics, home healthcare services and telehealth without broader outpatient component were excluded. Studies were included if they took place in outpatient healthcare settings providing long-term chronic care, such as primary care offices, specialty clinics, day care hospitals, rehabilitation centers, and dialysis centers. Studies in end-stage or palliative care facilities, urgent care centers including retail clinics, home healthcare services, or telehealth services without a broader outpatient care component were excluded.\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eTypes of evidence sources: This scoping review will consider all types of literature including experimental and quasi-experimental study designs, observational studies, qualitative studies, and reviews for inclusion. Protocols and grey literature that meet the inclusion criteria will also be considered.\u003c/p\u003e\u003c/li\u003e\u003c/ul\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003e2.3. Search Strategy\u003c/h2\u003e \u003cp\u003eThe search strategy was developed iteratively. Initially, a preliminary search was conducted in MEDLINE on 16 July 2024 to identify key articles on the topic. Text words in titles and abstracts of these articles, as well as relevant index and MeSH terms were used to develop a full search strategy aligned with the Population / Concept / Context framework:\u003c/p\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003e\u0026ldquo;patient-centered*\u0026rdquo; OR \u0026ldquo;patient centered*\u0026rdquo; OR \u0026ldquo;patient-centred*\u0026rdquo; OR \u0026ldquo;patient centred*\u0026rdquo; OR \u0026ldquo;person-centered*\u0026rdquo; OR \u0026ldquo;person centered*\u0026rdquo; OR \u0026ldquo;patient-focused\u0026rdquo; OR \u0026ldquo;patient focused\u0026rdquo; OR \u0026ldquo;value-based care\u0026rdquo; OR \u0026ldquo;value-based healthcare\u0026rdquo;\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003cp\u003eAND\u003c/p\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003e\u0026ldquo;elder*\u0026rdquo; OR \u0026ldquo;old\u0026rdquo; OR \u0026ldquo;older*\u0026rdquo; OR \u0026ldquo;senior*\u0026rdquo; OR \u0026ldquo;geriatric\u0026rdquo; OR \u0026ldquo;aging\u0026rdquo;\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003cp\u003eAND\u003c/p\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003e\u0026ldquo;outpatient*\u0026rdquo; OR \u0026ldquo;out-patient*\u0026rdquo; OR \u0026ldquo;ambulatory\u0026rdquo;\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003cp\u003eThe resulting search strategy, including all identified keywords and index terms, was adapted for additional databases. The review process involved systematic searches across PubMed, Web of Science, Scopus, and Google Scholar on 2 August 2024. The reference list of included sources of evidence were screened for additional studies. Only studies published in English were included, with no restrictions on the publication year to capture the full range of available evidence. Additionally, grey literature from healthcare and governmental organizations was included to capture non-academic sources relevant to PCC.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003e2.4. Evidence Screening and Selection\u003c/h2\u003e \u003cp\u003eFollowing the search, all identified citations were imported into EndNote 21.3 (Clarivate Analytics, PA, USA), and duplicates removed. In the first step of screening, two independent reviewers screened titles and abstracts to assess eligibility based on the inclusion criteria, with potentially relevant sources retrieved in full text. The full text of selected citations was further evaluated in detail against the inclusion criteria by the same two independent reviewers, and reasons for exclusions were recorded for reporting. Any disagreements between reviewers were resolved through discussion, or by consulting the corresponding author. The results of the search and the study inclusion process is reported in full in the final scoping review and presented in a PRISMA flow diagram [18]. Since the goal of this review was to map the current body of evidence on PCC in elderly outpatient settings, we did not conduct a risk of bias assessment.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003e2.5. Data Extraction\u003c/h2\u003e \u003cp\u003eData extraction was conducted using a structured form designed in a spreadsheet to capture study characteristics such as publication year, country, study design, target population, PCC definitions, core elements, PCC delivery models, interventions, barriers, and reported outcomes. Initially, three team members independently extracted data from the first five studies to assess consistency. Following this pilot extraction, their agreement was evaluated, and based on their recommendations, perspectives from key stakeholders were added to both the research questions and the extraction sheet to enhance comprehensiveness. Any discrepancies between team members during extraction were resolved by the corresponding author.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003e2.6. Data Analysis\u003c/h2\u003e \u003cp\u003eThe data were synthesized narratively to highlight PCC definitions, elements, stakeholder perspectives, barriers and effectiveness in elderly outpatient settings. Tables will be used to summarize study characteristics and thematic findings. Findings were contextualized to support PCC integration into LMICs\u0026rsquo; healthcare systems.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003e2.7. Declaration of AI-Assisted Technologies Use\u003c/h2\u003e \u003cp\u003eDuring the preparation of this work, the authors used ChatGPT in order to refine language and clarity. The authors reviewed and edited the content as needed and take full responsibility for the content of the publication.\u003c/p\u003e \u003c/div\u003e"},{"header":"3. Results","content":"\u003cp\u003eA total of 1474 sources of evidence were identified through the database search. After the removal of 340 duplicates, 1134 records remained for title and abstract screening against the inclusion criteria. From these, we retrieved 112 records for full text review, of which 59 met the inclusion criteria and with 17 additional studies identified from the reference lists of included sources, resulted in final 76 records for data extraction [Figure 1].\u003c/p\u003e\n\u003cp\u003eThe included studies, published between 2000 and 2024, represent research from 15 countries, with most originating from the US. Of note, more than 95% of included studies were conducted in countries with high-income economies as classified by the World Bank for the current 2025 fiscal year [19]. The majority of studies employed experimental and quasi-experimental designs (25) and qualitative research methods (22). The remaining studies utilized theoretical or conceptual frameworks (14), mixed methods research (7), systematic reviews (6) and observational studies (2). The studies addressed a broad range of PCC concept in elderly outpatient settings, including definitions and conceptual frameworks of PCC, stakeholder perspectives, barriers to its implementation, and PCC-aligned care delivery models or interventions along with their outcomes.\u003c/p\u003e\n\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e\n \u003ch2\u003e3.1. Definitions and Core Elements of PCC\u003c/h2\u003e\n \u003cp\u003eThe definitions and core elements of PCC varied across frameworks and organizations, reflecting diverse perspectives on how to approach and enact it, as PCC is still an evolving area of healthcare [Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e]. However, most definitions shared overarching themes, including partnership with the patient (and caregivers) in decision-making, seeing the whole person in the patient and coordination of care across multiple disciplines. In addition to the \u0026ldquo;patient-centered care\u0026rdquo; term, several other related terminologies are used by frameworks, including person-centered care [20\u0026ndash;27], people-centered care [28], relationship-centered care [20, 29], and client-centered care [16]. Majority of included studies adopted the definition by the Institute of Medicine, emphasizing respectful, quality care guided by patient\u0026rsquo;s goals, needs and expressed desires [3]. Core components of patient centeredness include key components of trust-building provider-patient relationships [22, 23, 28], dignity [26, 30\u0026ndash;32] and creating an enabling environment [21, 25, 26, 28, 30].\u0026nbsp;\u003c/p\u003e\n \u003cdiv class=\"gridtable\"\u003e\n \u003ctable id=\"Tab1\" border=\"1\"\u003e\n \u003ccaption\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eFrameworks of PCC and their principles.\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eFramework\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eQuoted definition\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eQuoted dimensions\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eInstitute of Medicine (now, known as the National Academy of Medicine)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026ldquo;Providing care that is respectful of and responsive to individual patient preferences, needs, and values and ensuring that patient values guide all clinical decisions [3].\u0026rdquo;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eEndorsed seven dimensions proposed by Gerteis et al.:\u003c/p\u003e\n \u003cp\u003e- \u0026ldquo;Respectful to patients\u0026rsquo; values, preferences, and expressed needs\u003c/p\u003e\n \u003cp\u003e- Transition and community\u003c/p\u003e\n \u003cp\u003e- Involvement of family and friends\u003c/p\u003e\n \u003cp\u003e- Coordination and integration of care\u003c/p\u003e\n \u003cp\u003e- Provide information, communication, and education\u003c/p\u003e\n \u003cp\u003e- Physical comfort\u003c/p\u003e\n \u003cp\u003e- Emotional support \u0026ndash; relieving fear and anxiety [31]\u0026rdquo;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePicker Institute [23]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026ldquo;Putting people at the heart of health and social services, including care, support, and enablement. It is an approach where users are recognized as individuals, encouraged to play an active role in their care, and where their needs and preferences are understood and respected.\u0026rdquo;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e- \u0026ldquo;Involvement in decisions and respect for preferences\u003c/p\u003e\n \u003cp\u003e- Continuity of care and smooth transitions\u003c/p\u003e\n \u003cp\u003e- Involvement and support for family and carers\u003c/p\u003e\n \u003cp\u003e- Effective treatment by trusted professionals\u003c/p\u003e\n \u003cp\u003e- Clear information, communication and support for self-care\u003c/p\u003e\n \u003cp\u003e- Attention to physical and environmental needs\u003c/p\u003e\n \u003cp\u003e- Emotional support, empathy and respect\u003c/p\u003e\n \u003cp\u003e- Fast access to reliable healthcare advice\u0026rdquo;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eKing\u0026rsquo;s Fund [20]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e- \u0026ldquo;Integrated care centred around the individual\u0026rsquo;s needs\u003c/p\u003e\n \u003cp\u003e- Healthy, active ageing and supporting independence\u003c/p\u003e\n \u003cp\u003e- Living well with simple or stable long-term conditions\u003c/p\u003e\n \u003cp\u003e- Living well with complex co-morbidities, dementia and frailty\u003c/p\u003e\n \u003cp\u003e- Rapid support close to home in times of crisis\u003c/p\u003e\n \u003cp\u003e- Good acute hospital care when needed\u003c/p\u003e\n \u003cp\u003e- Good discharge planning and post-discharge support\u003c/p\u003e\n \u003cp\u003e- Good rehabilitation and re-ablement after acute illness or injury\u003c/p\u003e\n \u003cp\u003e- High-quality nursing and residential care for those who need it\u003c/p\u003e\n \u003cp\u003e- Choice, control and support towards the end of life\u0026rdquo;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eInternational Alliance of Patients\u0026apos; Organizations [30]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026ldquo;Patient-centred healthcare is designed, organized and practised with patient at the centre.\u0026quot;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e- \u0026ldquo;Respect\u003c/p\u003e\n \u003cp\u003e- Choice and engagement\u003c/p\u003e\n \u003cp\u003e- Patient involvement in health policy\u003c/p\u003e\n \u003cp\u003e- Access and support\u003c/p\u003e\n \u003cp\u003e- Information\u0026rdquo;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eCenters for Medicare \u0026amp; Medicaid Services [22]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026ldquo;Integrated health care services delivered in a setting and manner that is responsive to individuals and their goals, values and preferences, in a system that supports good provider\u0026ndash;patient communication and empowers individuals receiving care and providers to make effective care plans together.\u0026rdquo;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e- \u0026ldquo;Care that\u0026rsquo;s guided and informed by patients\u0026rsquo; goals, preferences, and values\u003c/p\u003e\n \u003cp\u003e- Success measured by patient-reported outcomes\u003c/p\u003e\n \u003cp\u003e- Integrated and coordinated care across health systems, providers, and care settings\u003c/p\u003e\n \u003cp\u003e- Managing chronic and complex conditions\u003c/p\u003e\n \u003cp\u003e- Relationships built on trust and a commitment to long-term well-being\u0026rdquo;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eWHO Framework for Integrated People-Centered Health Services [28]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026ldquo;An approach to care that consciously adopts individuals\u0026rsquo;, carers\u0026rsquo;, families\u0026rsquo; and communities\u0026rsquo; perspectives as participants in, and beneficiaries of, trusted health systems that are organized around the comprehensive needs of people rather than individual diseases, and respects social references.\u0026rdquo;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e- \u0026ldquo;Empowering and engaging people and communities\u003c/p\u003e\n \u003cp\u003e- Strengthening governance and accountability\u003c/p\u003e\n \u003cp\u003e- Reorienting the model of care\u003c/p\u003e\n \u003cp\u003e- Coordinating services within and across sectors\u003c/p\u003e\n \u003cp\u003e- Creating an enabling environment\u0026rdquo;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eBisognano and Schummers [36]\u003c/p\u003e\n \u003cp\u003e(Institute for Healthcare Improvement)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026ldquo;Flipping healthcare means flipping the balance of care from the hospital to the community; the balance of delivery from individual providers to care teams; the balance of power from the provider to the patient and family; the balance of costs from treatment to prevention and co-production; and the balance of emphasis from volume to value and from healthcare to health. Truly person centred healthcare must consider and seek to understand the entire spectrum of social and economic factors that affect a person\u0026rsquo;s health, not merely the narrow slice of how or why a patient presents at the hospital or clinic.\u0026rdquo;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNational Health Service [21]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026ldquo;Focusing care on the needs of individual. Ensuring that people\u0026apos;s preferences, needs and values guide clinical decisions, and providing care that is respectful of and responsive to them. Health and wellbeing outcomes need to be co-produced by individuals and members of the workforce working in partnership, with evidence suggesting that this provides better patient outcomes and costs less to health and care systems.\u0026rdquo;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e- \u0026ldquo;Services are created in partnership with citizens and communities\u003c/p\u003e\n \u003cp\u003e- Personalised care\u003c/p\u003e\n \u003cp\u003e- Coordinated care\u003c/p\u003e\n \u003cp\u003e- Patient empowering\u003c/p\u003e\n \u003cp\u003e- Involvement and support of carers\u003c/p\u003e\n \u003cp\u003e- Focus is on quality and narrowing inequalities\u0026rdquo;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eHealth Foundation [26]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026ldquo;In person-centred care, health and social care professionals work collaboratively with people who use services. Person-centred care supports people to develop the knowledge, skills and confidence they need to more effectively manage and make informed decisions about their own health and health care. It is coordinated and tailored to the needs of the individual. And, crucially, it ensures that people are always treated with dignity, compassion and respect.\u0026rdquo;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e- \u0026ldquo;Affording people dignity, compassion and respect\u003c/p\u003e\n \u003cp\u003e- Offering coordinated care, support or treatment\u003c/p\u003e\n \u003cp\u003e- Offering personalised care, support or treatment\u003c/p\u003e\n \u003cp\u003e- Supporting people to recognise and develop their own strengths and abilities to enable them to live an independent and fulfilling life\u0026rdquo;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMead and Bower [117]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e- \u0026ldquo;Biopsychosocial perspective\u003c/p\u003e\n \u003cp\u003e- Patient-as-person\u003c/p\u003e\n \u003cp\u003e- Sharing and power of responsibility\u003c/p\u003e\n \u003cp\u003e- Therapeutic alliance\u003c/p\u003e\n \u003cp\u003e- Doctor-as-person\u0026rdquo;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eLangberg et al. [118]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e- \u0026ldquo;Biopsychosocial perspective\u003c/p\u003e\n \u003cp\u003e- Patient-as-person\u003c/p\u003e\n \u003cp\u003e- Sharing and power of responsibility\u003c/p\u003e\n \u003cp\u003e- Therapeutic alliance\u003c/p\u003e\n \u003cp\u003e- Doctor-as-person\u003c/p\u003e\n \u003cp\u003e- Coordinated care\u0026rdquo;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eInstitute for Patient- and Family-Centered Care [32]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026ldquo;An approach to the planning, delivery, and evaluation of health care that is grounded in mutually beneficial partnerships among health care providers, patients, and families.\u0026rdquo;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e- \u0026ldquo;Participation in care and decision-making at the level they choose\u003c/p\u003e\n \u003cp\u003e- Respect and dignity\u003c/p\u003e\n \u003cp\u003e- Information sharing\u003c/p\u003e\n \u003cp\u003e- Collaboration\u0026rdquo;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMcCormack \u0026amp; McCance [27]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e- \u0026ldquo;Working with patient\u0026rsquo;s beliefs and values\u003c/p\u003e\n \u003cp\u003e- Engagement\u003c/p\u003e\n \u003cp\u003e- Shared decision making\u003c/p\u003e\n \u003cp\u003e- Providing sympathetic presence\u003c/p\u003e\n \u003cp\u003e- Providing for physical needs\u0026rdquo;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eEpstein et al. [37]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e- \u0026ldquo;An informed and involved patient and family\u003c/p\u003e\n \u003cp\u003e- Receptive and responsive health professionals who can focus on the disease and knowing the patient\u003c/p\u003e\n \u003cp\u003e- A well-coordinated and well-integrated health care environment that supports the efforts of patients, families and their clinicians\u0026rdquo;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eLusk and Fater [119]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e- \u0026ldquo;Encouraging patient autonomy\u003c/p\u003e\n \u003cp\u003e- Individualizing patient care\u003c/p\u003e\n \u003cp\u003e- Caring attitude\u0026rdquo;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePlanetree [25]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026ldquo;Care focused on the needs of individuals, guided by peoples\u0026rsquo; preferences and values, and includes supporting structures, policies, and practices that create a culture of quality, compassion, and partnership across the continuum of care.\u0026rdquo;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e- \u0026ldquo;Partnership\u003c/p\u003e\n \u003cp\u003e- Quality\u003c/p\u003e\n \u003cp\u003e- Compassion\u0026rdquo;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n \u003c/div\u003e\n \u003cp\u003eAn essential component highlighted in the Planetree and Health Foundation frameworks is compassionate care, which has been described as a missing ingredient in care provision [25, 26, 33]. Compassion in healthcare is defined as empathetically understanding the patient\u0026rsquo;s distress and suffering, coupled with emotional resonance and effort to relieve it [34]. Another interesting central element outlined in the framework by the Centers for Medicare \u0026amp; Medicaid Services (CMS) is the measurement of care success through patient-reported outcomes (PROs), which are gathered directly from patients without any interpretation [22]. This approach allows healthcare systems to assess whether the services provided are truly aligned with patient-centered care. By comparing expected outcomes with actual patient experiences, and identifying gaps in care, PROs ensures that patient care is continually refined to meet the needs and preferences of patients, ultimately enhancing the quality of care delivered [35].\u003c/p\u003e\n \u003cp\u003eImportantly, the PCC is not limited to relationships between the physician and the patient but extends to interactive communication with nurses, staff, other healthcare provider, and family members or trusted friends, all as integral participants in the care process [22, 23, 25, 28, 30\u0026ndash;32, 36, 37]. These diverse but interconnected elements frame PCC as a comprehensive, systemic approach. It incorporates individual autonomy, family involvement, and community participation, supported by an infrastructure of relational care, coordinated systems, and technological innovation, to meet the holistic needs of patients and populations.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec12\" class=\"Section2\"\u003e\n \u003ch2\u003e3.2. Stakeholders\u0026rsquo; Perspectives on PCC Implementation in Elderly Outpatient Settings\u003c/h2\u003e\n \u003cp\u003eDespite the heterogeneous landscape of patient-centeredness definitions, capturing the voices of elderly patients and healthcare providers/policymakers in our scoping review can provide valuable insights into how PCC is envisioned and should be put into practice. Both groups emphasized the importance of comprehensive care coordination [16, 29, 38\u0026ndash;47] and individualized plans [16, 29, 40, 41, 44, 46, 48\u0026ndash;50] to address the unique challenges of elderly outpatient care. Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e outlines the perspectives of stakeholders regarding the implementation of PCC in elderly outpatient settings. While it highlights the similarities and unique priorities identified by the two stakeholder groups, their specific focus areas reveal distinct priorities as well.\u003c/p\u003e\n \u003cdiv class=\"gridtable\"\u003e\n \u003ctable id=\"Tab2\" border=\"1\"\u003e\n \u003ccaption\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003ePerspectives of stakeholders on the implementation of PCC in outpatient settings for elderly patients.\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth colspan=\"2\" align=\"left\"\u003e\n \u003cp\u003eWhat does PCC in elderly outpatient settings mean for healthcare providers and policymakers?\u003c/p\u003e\n \u003c/th\u003e\n \u003cth colspan=\"2\" align=\"left\"\u003e\n \u003cp\u003eWhat does PCC mean for older adults in outpatient settings?\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eHolistic/ whole person\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e[29, 38, 41, 48, 51, 52]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePreserved independence and control/ maintenance of independent activity of daily living\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e[39\u0026ndash;41, 43, 46, 47, 53]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eCare coordination\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e[16, 29, 38\u0026ndash;43]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eFeeling valued and respected/ dignity\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e[39, 45\u0026ndash;47]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMultidisciplinary team-based care\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e[16, 38\u0026ndash;41, 51, 52]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSeen as a meaningful human being\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e[41, 47, 53]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eInterprofessional care\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e[40, 42, 43]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eHolistic\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e[46, 49, 54]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eComprehensive care\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e[38, 42]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eContinuous care/ consistency in care\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e[46, 47, 49, 53, 54]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eIntegrated care\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e[40, 42, 52]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eCare coordination\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e[39, 44\u0026ndash;47]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eIndividualized plan of care\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e[16, 29, 40, 41]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMultidisciplinary care\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e[40, 44, 45, 49, 54]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePatient\u0026rsquo;s goal and choice-oriented care\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e[16, 29]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eIntegrated care\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e[45, 48, 54]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePatient- (and family-) centered communication\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e[38, 41, 52]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePersonal goal and choice-oriented care\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e[43, 45, 48\u0026ndash;50]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eStimulating communication\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e[39]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eIndividualized plan of care\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e[40, 44, 46, 48\u0026ndash;50]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eInteractive communication\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e[39]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eBeing involved/ engaged\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e[39, 43, 45, 46, 48, 54]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMotivational interviewing\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e[16]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eEasy access to care/ proximity\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e[39, 44, 46, 47, 50, 53]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eShared decision making\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e[43, 48, 52]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eKnowing what comes next\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e[39, 40]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePatient engagement\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e[43, 48, 52]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eFeeling informed\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e[39, 44, 46, 47]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePatient education and empowerment\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e[43]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eBeing educated\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e[44\u0026ndash;46, 48, 50]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eCompassion\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e[39]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eBeing empowered/ self-care\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e[48]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSympathy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e[48]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePatient activation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e[48]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eEmpathy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e[41]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eBeing centered at communication\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e[46]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eTrustful relationship with staff\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e[29]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eFeeling listened to/ open communication\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e[43, 49, 50]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePatient-centered blended eHealth applications\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e[16, 40]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMotivational interviewing\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e[46]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAccessible care\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e[41]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eFeeling safe\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e[47]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eProactive\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e[41]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eTrustful relationship with staff\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e[39, 40, 46, 47, 49, 53]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eCompassion\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e[50]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n \u003c/div\u003e\n \u003cp\u003eFor healthcare providers and policymakers, PCC was largely defined by a focus on delivering holistic [29, 38, 41, 48, 51, 52], integrated [40, 42, 52], and team-based care [16, 38\u0026ndash;41, 51, 52]. They underscored elements such as interprofessional care [40, 42, 43], and comprehensive services [38, 42] to address the multifaceted needs of elderly patients, while fostering effective communication with patients and their families [38, 41, 52] through interactive [39], stimulating [39], and motivational approaches [16]. In addition, healthcare professionals believed addition of tele-heath applications could make a positive contribution to optimizing the care and encouraging patients [16, 40].\u003c/p\u003e\n \u003cp\u003eElderly patients, on the other hand, viewed PCC through the lens of their lived experiences and personal priorities. Patients wanted to be empowered, have control on daily functioning and regain sense of control over their care, which they feel disempowered by their health conditions and perceived loss of identity [39\u0026ndash;41, 43, 46, 47, 53]. This patient statement, \u0026ldquo;\u003cem\u003eI tried by myself for as long as I could until my self-esteem came back. So that I could shower myself, and that I decide for myself, that I\u0026rsquo;m not tied to someone else\u003c/em\u003e\u0026rdquo;, clearly shows the importance of their need for a care that preserves their independence, autonomy and dignity [40]. They valued being recognized as meaningful individuals and emphasized the necessity for building real relationships with consistent staff, remembering them for more than just their illness [39, 40, 46, 47, 49, 53]. In addition, elderly patients stressed the importance of continuous and consistent care [46, 47, 49, 53, 54] and easy access to services [39, 44, 46, 47, 50, 53] that keeps them safe and engaged. Goal setting during shared decision making and knowing what comes next was also a recurring theme [39, 40].\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec13\" class=\"Section2\"\u003e\n \u003ch2\u003e3.3. Barriers to Implementing PCC in Elderly Outpatient Settings\u003c/h2\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cdiv class=\"gridtable\"\u003e\n \u003ctable id=\"Tab3\" border=\"1\"\u003e\n \u003ccaption\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eIdentified barriers to implementing PCC in outpatient settings for elderly patients.\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth colspan=\"2\" align=\"left\"\u003e\n \u003cp\u003eIndividual-level barriers\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eCost pressure\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e[29, 44, 61]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eTransport challenges\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e[40, 41, 50, 55, 57, 58]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eExplanations not tailored to patient knowledge-level\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e[45]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eLanguage barriers\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e[29, 53, 55, 56]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eLack of conversation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e[46]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePersonnel or individual inattention\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e[46]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eTechnological challenges\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e[40, 55, 57]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eCognitive and physical restraints\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e[41]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eCultural barriers\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e[29]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" align=\"left\"\u003e\n \u003cp\u003eSystem-level barriers\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eResource limitation/ insurance coverage\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e[16, 29, 40\u0026ndash;42, 49, 60]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eLack of time\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e[29, 40, 41, 46, 49, 51, 52, 55, 59, 61]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eLong waiting time and poor appointment scheduling\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e[44\u0026ndash;47, 50, 63]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eOrganizational obstacles/ infrastructure/ hospital bureaucracy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e[41, 42, 49, 59]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eInsufficient staff/overburdened staff\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e[16, 51, 55, 59, 61]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eLack of role clarity\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e[59, 62]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDisconnections within healthcare systems, and between healthcare practitioners and care allies\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e[55, 61]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eInadequate reimbursement\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e[41, 60]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eThe need to go through several levels of care before receiving the right treatment\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e[46, 61]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eCare fragmentation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e[46, 61]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eHigh turnover of healthcare professionals\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e[47, 53]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSpace constraints\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e[41, 55]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eLack of leadership\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e[42]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eHigh patient load\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e[61]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eHealthcare workers with double positions\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e[42]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eLack of ownership by participants\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e[54]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eRestricted opening time\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e[46]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eUnclear care pathways and assessment methods\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e[41, 51]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDecreased time efficiency\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e[62]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n \u003c/div\u003e\n \u003cp\u003eTable\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e3\u003c/span\u003e demonstrates barriers to implementing patient-centeredness within outpatient care delivery for older adults, categorized into individual-level and system-level challenges. Individual-level barriers largely involve factors affecting the interactions between patients and healthcare providers. Examples include staff inattention, lack of meaningful conversation and the use of overly technical medical terminology and language barriers [29, 45, 46, 53, 55, 56]. The presence of a family companion during consultations can minimize these issues by facilitating communication, improving the exchange of information, and helping clarify health-related instructions [56]. Language mismatches between patients and providers can further complicate the information exchange, causing confusion and a limited understanding of the patient\u0026rsquo; needs and experiences throughout the care pathway [29, 53]. Transportation difficulties are also another significant individual-level barrier [40, 41, 50, 55, 57, 58], emphasize the need for co-located or conveniently accessible care facilities to enhance coordination and ensure care delivery as a cohesive unit.\u003c/p\u003e\n \u003cp\u003eSystem-level barriers reflect structural and organizational obstacles that impede PCC implementation [41, 42, 49, 59]. Achieving PCC should be understood as a system-wide culture rather than merely a program embedded within ambulatory care practice and requires a financially sustainable reoriented care model [16, 60]. Securing adequate resources, particularly financial [16, 29, 40\u0026ndash;42, 49, 60] and workforce-related support [16, 51, 55, 59, 61] represents as the most significant challenges in this level. Support from top leaderships within health systems, non-profit financial structures, private funding and expanded insurance coverage could allow for more flexibility in delivering care under this models. In addition, lack of strong leadership [42], staff shortages [16, 51, 55, 59, 61], healthcare providers with double positions [42], and high turnover rates among professionals [47, 53] can disrupt care continuity, hamper the development of meaningful provider-patient relationships and diminish patients\u0026rsquo; sense of belonging. Organizing and addressing disconnections among care allies [55, 61], clarifying roles within multidisciplinary teams [59, 62], and streamlining care pathways [41, 51] can improve time efficiency and productivity, even without the need for a full redesign of the structural and organizational aspects of current care delivery models. Lastly, long waiting times and poor appointment scheduling [44\u0026ndash;47, 50, 63] further limit the accessibility and continuity of care, presenting significant barriers in implementing PCC.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec14\" class=\"Section2\"\u003e\n \u003ch2\u003e3.4. Practical Models of PCC and Patient-Centered Interventions in Elderly Outpatient Settings\u003c/h2\u003e\n \u003cp\u003eThis section describes the various models of practical PCC delivery and interventions identified in the studies. These models, grounded in patient-centered principles, have been proposed and/or implemented as a solution to address mentioned gaps in care delivery, especially for older adults with multiple chronic conditions. We classified these models into three levels of care: primary health care, specialized care, or an integrated care, where specialized services are incorporated into the existing primary care framework. Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e4\u003c/span\u003e provides a comprehensive overview of these strategies, detailing team composition, care attributes and services within the practice along with reported outcomes. The effectiveness of these models and interventions were evaluated using a ranges of outcomes, including patient-centered outcomes (e.g., care satisfaction and experience, quality of life, empowerment), clinical outcomes (e.g., disease management, symptom reduction, medication-related issues), and system-level outcomes (e.g., cost saving, reduced emergency department visits, hospitalizations).\u003c/p\u003e\n \u003cdiv class=\"gridtable\"\u003e\n \u003ctable id=\"Tab4\" border=\"1\"\u003e\n \u003ccaption\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003ePCC-affiliated models and interventions for older adults in the outpatient care practice.\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth colspan=\"8\" align=\"left\"\u003e\n \u003cp\u003ePrimary Care Patient-Centered Models\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eModel\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eTeam members\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" align=\"left\"\u003e\n \u003cp\u003eCare attributes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eIn-center services\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eOut-of-center services\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" align=\"left\"\u003e\n \u003cp\u003eOutcomes\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"6\" align=\"left\"\u003e\n \u003cp\u003ePCMH [64, 65] including its incorporation in Veterans Affairs through the Patient Aligned Care Teams (PACT) [69] and GeriPACT [70]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"6\" align=\"left\"\u003e\n \u003cp\u003e\u0026bull; Physicians\u003c/p\u003e\n \u003cp\u003e\u0026bull; Advanced practice nurses\u003c/p\u003e\n \u003cp\u003e\u0026bull; Physician assistants\u003c/p\u003e\n \u003cp\u003e\u0026bull; Behavioral health professionals\u003c/p\u003e\n \u003cp\u003e\u0026bull; Nurses\u003c/p\u003e\n \u003cp\u003e\u0026bull; Pharmacists\u003c/p\u003e\n \u003cp\u003e\u0026bull; Nutritionists\u003c/p\u003e\n \u003cp\u003e\u0026bull; SWs\u003c/p\u003e\n \u003cp\u003e\u0026bull; Educators\u003c/p\u003e\n \u003cp\u003e\u0026bull; Patient care coordinator\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" rowspan=\"6\" align=\"left\"\u003e\n \u003cp\u003e\u0026bull; Enhanced accessibility as the initial point of contact with the healthcare system\u003c/p\u003e\n \u003cp\u003e\u0026bull; Covering a broad range of individual healthcare needs\u003c/p\u003e\n \u003cp\u003e\u0026bull; Multidisciplinary coordination and integrated care\u003c/p\u003e\n \u003cp\u003e\u0026bull; Sustained partnership over time with patients\u003c/p\u003e\n \u003cp\u003e\u0026bull; Continuous system-based approach for quality and safety improvement\u003c/p\u003e\n \u003cp\u003e\u0026bull; Utilization of patient registries for population health management\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"6\" align=\"left\"\u003e\n \u003cp\u003e\u0026bull; Primary care\u003c/p\u003e\n \u003cp\u003e\u0026bull; Mental health evaluation\u003c/p\u003e\n \u003cp\u003e\u0026bull; Preventive care\u003c/p\u003e\n \u003cp\u003e\u0026bull; Focused geriatric care and assessment in GeriPACT\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"6\" align=\"left\"\u003e\n \u003cp\u003e\u0026bull; Collaboration with community organizations and local support groups including home health care\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" align=\"left\"\u003e\n \u003cp\u003eReduced ED visits, positive effects on patient and staff experiences and no change in hospital admissions [71]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" align=\"left\"\u003e\n \u003cp\u003eWith over three million member-month visits in nearly seven years of PCMH in Geisinger Health System:\u003c/p\u003e\n \u003cp\u003e\u0026bull; Total 7.9% cost saving\u003c/p\u003e\n \u003cp\u003e\u0026bull; Reduced acute inpatient costs [75]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" align=\"left\"\u003e\n \u003cp\u003eDifferent PCMH features affected expenditures in distinct ways. However, Even partial adoption of PCMH features helped practices improve healthcare quality while managing expenses [72].\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" align=\"left\"\u003e\n \u003cp\u003eWith over 3 years of surveillance on centers implementing PACT and covering one million older adults:\u003c/p\u003e\n \u003cp\u003e\u0026bull; No association between implementation progress index score and high cost healthcare expenditure [14]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" align=\"left\"\u003e\n \u003cp\u003eAfter one year of program implementation in Singapore:\u003c/p\u003e\n \u003cp\u003e\u0026bull; Significant declined ED, PCP and specialist visits relative to comparison group\u003c/p\u003e\n \u003cp\u003e\u0026bull; No change in hospitalizations [73]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" align=\"left\"\u003e\n \u003cp\u003eGeriPACT programs with mental and behavioral health provider in their team have higher success in management of psychological and cognitive conditions [74].\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" align=\"left\"\u003e\n \u003cp\u003eComprehensive Primary Care (CPC) initiative [66]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" align=\"left\"\u003e\n \u003cp\u003e\u0026bull; Physicians\u003c/p\u003e\n \u003cp\u003e\u0026bull; Nurse practitioners\u003c/p\u003e\n \u003cp\u003e\u0026bull; Physician assistants\u003c/p\u003e\n \u003cp\u003e\u0026bull; Patient care coordinators\u003c/p\u003e\n \u003cp\u003e\u0026bull; Behavioral health professionals\u003c/p\u003e\n \u003cp\u003e\u0026bull; Pharmacists\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" rowspan=\"2\" align=\"left\"\u003e\n \u003cp\u003e\u0026bull; Risk stratification of patients\u003c/p\u003e\n \u003cp\u003e\u0026bull; Coordinated team-based care management with involvement of patients/families\u003c/p\u003e\n \u003cp\u003e\u0026bull; Electronic health record integration\u003c/p\u003e\n \u003cp\u003e\u0026bull; Multi-payer payment structure\u003c/p\u003e\n \u003cp\u003e\u0026bull; Continuous care along with advanced care accessibility\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" align=\"left\"\u003e\n \u003cp\u003e\u0026bull; Comprehensive range of primary care\u003c/p\u003e\n \u003cp\u003e\u0026bull; Preventive care\u003c/p\u003e\n \u003cp\u003e\u0026bull; Care transition\u003c/p\u003e\n \u003cp\u003e\u0026bull; Behavioral health integration\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" align=\"left\"\u003e\n \u003cp\u003e\u0026bull; Electronic health record incentive programs\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" align=\"left\"\u003e\n \u003cp\u003eIn first two years of implementation at 500 primary care practices:\u003c/p\u003e\n \u003cp\u003e\u0026bull; No significant change in mean monthly Medicare costs per beneficiary relative to comparison practices\u003c/p\u003e\n \u003cp\u003e\u0026bull; Improved patient experience\u003c/p\u003e\n \u003cp\u003e\u0026bull; Decreased PCP visits by 3% [76]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" align=\"left\"\u003e\n \u003cp\u003eCumulative 4-year findings:\u003c/p\u003e\n \u003cp\u003e\u0026bull; Significant improvement in care delivery based on practice survey particularly in its first 2 years of implementation\u003c/p\u003e\n \u003cp\u003e\u0026bull; No significant changes in expenditure growth during CPC\u003c/p\u003e\n \u003cp\u003e\u0026bull; Less growth in ED visits relative to comparison group\u003c/p\u003e\n \u003cp\u003e\u0026bull; No significant difference in physician work satisfaction and burnout measures [77]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSage-atAge (Wijs Grijs) [120]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026bull; Geriatrician\u003c/p\u003e\n \u003cp\u003e\u0026bull; Geriatric nurse\u003c/p\u003e\n \u003cp\u003e\u0026bull; Pharmacist\u003c/p\u003e\n \u003cp\u003e\u0026bull; Dental care worker\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" align=\"left\"\u003e\n \u003cp\u003e\u0026bull; Proactive screening of care profile based on surveys and indicators\u003c/p\u003e\n \u003cp\u003e\u0026bull; Referral of high risk and complex patients to the program\u003c/p\u003e\n \u003cp\u003e\u0026bull; Comprehensive geriatric assessment by geriatrician or nurse\u003c/p\u003e\n \u003cp\u003e\u0026bull; Shared decision making between care team and patients and consultation from out-of-center professionals if needed\u003c/p\u003e\n \u003cp\u003e\u0026bull; Collaborating with primary physician and transfer of recommendations\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026bull; Primary care\u003c/p\u003e\n \u003cp\u003e\u0026bull; Social/psychological management strategies\u003c/p\u003e\n \u003cp\u003e\u0026bull; Dental care\u003c/p\u003e\n \u003cp\u003e\u0026bull; Medication management\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026bull; Collaboration with PCPs\u003c/p\u003e\n \u003cp\u003e\u0026bull; Referral to other professionals if needed\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" align=\"left\"\u003e\n \u003cp\u003eAddition of motivational interviewing and goal setting in the framework of Sage-atAge\u0026thinsp;+\u0026thinsp;yielded no between group difference in well-being score.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eProPCC Programme [108]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026bull; Geriatrician\u003c/p\u003e\n \u003cp\u003e\u0026bull; Geriatric nurse\u003c/p\u003e\n \u003cp\u003e\u0026bull; SW\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" align=\"left\"\u003e\n \u003cp\u003e\u0026bull; Collaboration with primary care network\u003c/p\u003e\n \u003cp\u003e\u0026bull; Weekly multidisciplinary meetings for case management\u003c/p\u003e\n \u003cp\u003e\u0026bull; Biweekly meetings between the ProPCC team and other horizontal teams such as home service agencies and palliative care at home teams\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026bull; Primary care\u003c/p\u003e\n \u003cp\u003e\u0026bull; Transitional care\u003c/p\u003e\n \u003cp\u003e\u0026bull; Social management strategies\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026bull; Connection with community and social services\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" align=\"left\"\u003e\n \u003cp\u003eWith six month of implementation and covering 264 patients:\u003c/p\u003e\n \u003cp\u003e\u0026bull; Significantly decreased ED visits, hospitalizations and days at hospital with shift to increased primary care visits\u003c/p\u003e\n \u003cp\u003e\u0026bull; Increased days at home\u003c/p\u003e\n \u003cp\u003e\u0026bull; Healthcare cost saving by 46.3%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSenior Health and Wellness Center (SHWC) [60]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026bull; Geriatricians: 3\u003c/p\u003e\n \u003cp\u003e\u0026bull; Nurse practitioner\u003c/p\u003e\n \u003cp\u003e\u0026bull; Nurses\u003c/p\u003e\n \u003cp\u003e\u0026bull; SW\u003c/p\u003e\n \u003cp\u003e\u0026bull; Dietician\u003c/p\u003e\n \u003cp\u003e\u0026bull; Pharmacist\u003c/p\u003e\n \u003cp\u003e\u0026bull; Receptionist\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" align=\"left\"\u003e\n \u003cp\u003e\u0026bull; Initial health assessment and risk screening\u003c/p\u003e\n \u003cp\u003e\u0026bull; Interdisciplinary primary care management of patients\u003c/p\u003e\n \u003cp\u003e\u0026bull; Weekly team meeting: Chaplain, physical therapist, home health nurse, and behavioral health professional will join as well.\u003c/p\u003e\n \u003cp\u003e\u0026bull; Patient case reviewed every three months\u003c/p\u003e\n \u003cp\u003e\u0026bull; Long-term collaboration with community PCPs\u003c/p\u003e\n \u003cp\u003e\u0026bull; Improvement of patient self-care\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026bull; Primary care\u003c/p\u003e\n \u003cp\u003e\u0026bull; Nutritional planning\u003c/p\u003e\n \u003cp\u003e\u0026bull; Daily living activity evaluation\u003c/p\u003e\n \u003cp\u003e\u0026bull; Falls/gait evaluation\u003c/p\u003e\n \u003cp\u003e\u0026bull; Psychological and behavioral management strategies\u003c/p\u003e\n \u003cp\u003e\u0026bull; Immunization\u003c/p\u003e\n \u003cp\u003e\u0026bull; Physical therapy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026bull; Collaboration with community agencies and local support groups including Alzheimer\u0026rsquo;s Association and local Area Aging Agency and senior volunteers\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" align=\"left\"\u003e\n \u003cp\u003eWith 10667 visits and covering 1605 active patients in 3 years of implementation:\u003c/p\u003e\n \u003cp\u003e\u0026bull; Higher employee satisfaction\u003c/p\u003e\n \u003cp\u003e\u0026bull; Improved teamwork\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eTaiwan Integrated Geriatric Care (TIGER) [121]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026bull; Physicians\u003c/p\u003e\n \u003cp\u003e\u0026bull; Trained nurses\u003c/p\u003e\n \u003cp\u003e\u0026bull; Pharmacist\u003c/p\u003e\n \u003cp\u003e\u0026bull; Nutritionist\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" align=\"left\"\u003e\n \u003cp\u003e\u0026bull; Recruitment of older adults with three chronic diseases\u003c/p\u003e\n \u003cp\u003e\u0026bull; Implementation of twelve-month group-based multiple domain (physical activities, brain training and nutritional planning) intervention (similar to THISCE) integrated into primary care of patients and comprehensive geriatric assessment\u003c/p\u003e\n \u003cp\u003e\u0026bull; Patient education\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026bull; Primary care\u003c/p\u003e\n \u003cp\u003e\u0026bull; Care management for multimorbidity\u003c/p\u003e\n \u003cp\u003e\u0026bull; Patient education\u003c/p\u003e\n \u003cp\u003e\u0026bull; Mental health\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026bull; Phone reminders\u003c/p\u003e\n \u003cp\u003e\u0026bull; Home assignments\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" align=\"left\"\u003e\n \u003cp\u003eAfter one year of intervention implementation at 6 clinical sites:\u003c/p\u003e\n \u003cp\u003e\u0026bull; Significantly higher average physical component scores relative to usual care group\u003c/p\u003e\n \u003cp\u003e\u0026bull; Significantly higher mental component score at the end of follow-up\u003c/p\u003e\n \u003cp\u003e\u0026bull; Reduced limited activities of daily living, slowness and overall pain\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"8\" align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eIntegrated Primary-Specialty Patient-Centered Models\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eModel\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" align=\"left\"\u003e\n \u003cp\u003eTeam members\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eCare attributes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eIn-center services\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eOut-of-center services\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" align=\"left\"\u003e\n \u003cp\u003eOutcomes\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"8\" align=\"left\"\u003e\n \u003cp\u003eChronic diseases\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eBehavioral Health and Chronic Illness Care Intervention [90]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" align=\"left\"\u003e\n \u003cp\u003e\u0026bull; Physician\u003c/p\u003e\n \u003cp\u003e\u0026bull; Nurses\u003c/p\u003e\n \u003cp\u003e\u0026bull; Physician assistants\u003c/p\u003e\n \u003cp\u003e\u0026bull; RN health coaches\u003c/p\u003e\n \u003cp\u003e\u0026bull; Behavioral health triage therapists\u003c/p\u003e\n \u003cp\u003e\u0026bull; Panel managers\u003c/p\u003e\n \u003cp\u003e\u0026bull; Practice managers\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026bull; Behavioral health screening at triage\u003c/p\u003e\n \u003cp\u003e\u0026bull; Multidisciplinary case management and shared decision making based on guidelines\u003c/p\u003e\n \u003cp\u003e\u0026bull; Self-management training\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026bull; Primary care\u003c/p\u003e\n \u003cp\u003e\u0026bull; Behavioral/psychological health screening and management strategies\u003c/p\u003e\n \u003cp\u003e\u0026bull; Care management for HF, DM, HTN, obesity and asthma\u003c/p\u003e\n \u003cp\u003e\u0026bull; Self-care educations\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026bull; Electronic patient portal\u003c/p\u003e\n \u003cp\u003e\u0026bull; Connection to community resources\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" align=\"left\"\u003e\n \u003cp\u003eFrom year two of implementation onward in 22 practice centers:\u003c/p\u003e\n \u003cp\u003e\u0026bull; Increased recommended diabetes care acceptance\u003c/p\u003e\n \u003cp\u003e\u0026bull; Decreased ED visits by 4.9% relative to comparison group\u003c/p\u003e\n \u003cp\u003e\u0026bull; No change in Medicare expenditure and hospitalizations\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePatient-Centred Team Intervention [109]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" align=\"left\"\u003e\n \u003cp\u003e\u0026bull; Physician\u003c/p\u003e\n \u003cp\u003e\u0026bull; Geriatric nurses\u003c/p\u003e\n \u003cp\u003e\u0026bull; Physician assistants\u003c/p\u003e\n \u003cp\u003e\u0026bull; Nurse coordinators\u003c/p\u003e\n \u003cp\u003e\u0026bull; Occupational therapist\u003c/p\u003e\n \u003cp\u003e\u0026bull; Physiotherapist\u003c/p\u003e\n \u003cp\u003e\u0026bull; Pharmacist\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026bull; Proactive selection of high cost high complexity patients\u003c/p\u003e\n \u003cp\u003e\u0026bull; Comprehensive geriatric evaluation\u003c/p\u003e\n \u003cp\u003e\u0026bull; Complex patient issues addressed by a multidisciplinary geriatric team together with the patient\u003c/p\u003e\n \u003cp\u003e\u0026bull; Continuous care process and adjustment based on patient feedbacks\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026bull; Primary care\u003c/p\u003e\n \u003cp\u003e\u0026bull; Secondary care\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd colspan=\"2\" align=\"left\"\u003e\n \u003cp\u003eDuring six months of implementation and including 439 multimorbid elderly patients:\u003c/p\u003e\n \u003cp\u003e\u0026bull; Reduced use of ED, bed days and re-admission\u003c/p\u003e\n \u003cp\u003e\u0026bull; Substantially reduced mortality rate\u003c/p\u003e\n \u003cp\u003e\u0026bull; Increased outpatient visits\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eLocal, collaborative, stepped and\u003c/p\u003e\n \u003cp\u003epersonalized care management for older people with Chronic diseases (LoChro-Care) [122]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" align=\"left\"\u003e\n \u003cp\u003e\u0026bull; Nurse specialized in health education\u003c/p\u003e\n \u003cp\u003e\u0026bull; SW\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026bull; Recruitment of multimorbid older adults and initial comprehensive assessment by chronic case manager (nurse or SW)\u003c/p\u003e\n \u003cp\u003e\u0026bull; Personalized care navigation through interaction with patients\u003c/p\u003e\n \u003cp\u003e\u0026bull; Multidisciplinary geriatric team meeting every two months or in the case of urgent need\u003c/p\u003e\n \u003cp\u003e\u0026bull; Care continuity in period of a twelve months program and collaboration with PCPs\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026bull; Primary care\u003c/p\u003e\n \u003cp\u003e\u0026bull; Assessment of activity of daily living, mobility and mood/cognition\u003c/p\u003e\n \u003cp\u003e\u0026bull; Medication management\u003c/p\u003e\n \u003cp\u003e\u0026bull; Patient education\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026bull; Link to local geriatric support services\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" align=\"left\"\u003e\n \u003cp\u003eWith 12 months of intervention implementation in ~\u0026thinsp;250 patients:\u003c/p\u003e\n \u003cp\u003e\u0026bull; No significant between-group difference in physical, psychological and social composite scores compared to usual care group with both groups experiencing decline in their composite scores\u003c/p\u003e\n \u003cp\u003e\u0026bull; No significant between-group difference in care satisfaction [123]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"8\" align=\"left\"\u003e\n \u003cp\u003ePost-discharge transitional care\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eTransitional Care Manager [82] into PCMH\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" align=\"left\"\u003e\n \u003cp\u003e\u0026bull; Physician\u003c/p\u003e\n \u003cp\u003e\u0026bull; Nurses\u003c/p\u003e\n \u003cp\u003e\u0026bull; Specialists\u003c/p\u003e\n \u003cp\u003e\u0026bull; Health educator\u003c/p\u003e\n \u003cp\u003e\u0026bull; Pharmacist\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026bull; Proactively referred patients from PCPs\u003c/p\u003e\n \u003cp\u003e\u0026bull; Patient guideline based risk stratification\u003c/p\u003e\n \u003cp\u003e\u0026bull; Shared multidisciplinary team problem-solving with patient/family and continuity of monitoring\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026bull; Patient education\u003c/p\u003e\n \u003cp\u003e\u0026bull; Nutritional planning\u003c/p\u003e\n \u003cp\u003e\u0026bull; Medication review\u003c/p\u003e\n \u003cp\u003e\u0026bull; Medical management\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd colspan=\"2\" align=\"left\"\u003e\n \u003cp\u003ePreliminary enrollment of 50 patients over 6 months, showed:\u003c/p\u003e\n \u003cp\u003e\u0026bull; Declined ED visits and hospitalizations\u003c/p\u003e\n \u003cp\u003e\u0026bull; Improved patient care experience and resource saving\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePerson-Centered Lifestyle Change Intervention Model [124]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" align=\"left\"\u003e\n \u003cp\u003e\u0026bull; Specialized nurses\u003c/p\u003e\n \u003cp\u003e\u0026bull; Other patients\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026bull; Invitation of older adult patient hospitalized during the last months to practice groups with other patients and nurses\u003c/p\u003e\n \u003cp\u003e\u0026bull; Self-management and stress assessment at beginning and every 4 weeks during a 6\u0026ndash;8 months program\u003c/p\u003e\n \u003cp\u003e\u0026bull; Active participation of patient and education programs\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026bull; Psychological/emotional and social management strategies\u003c/p\u003e\n \u003cp\u003e\u0026bull; Patient empowerment program and education\u003c/p\u003e\n \u003cp\u003e\u0026bull; Peer groups\u003c/p\u003e\n \u003cp\u003e\u0026bull; Relaxation exercises\u003c/p\u003e\n \u003cp\u003e\u0026bull; Lifestyle coaching\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd colspan=\"2\" align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eTransitional Care Stroke Intervention [107]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" align=\"left\"\u003e\n \u003cp\u003e\u0026bull; RNs\u003c/p\u003e\n \u003cp\u003e\u0026bull; Occupational therapist\u003c/p\u003e\n \u003cp\u003e\u0026bull; Physical therapist\u003c/p\u003e\n \u003cp\u003e\u0026bull; SW\u003c/p\u003e\n \u003cp\u003e\u0026bull; SLP\u003c/p\u003e\n \u003cp\u003e\u0026bull; Patient care coordinator\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026bull; Designated for older adult with stroke discharged from hospital\u003c/p\u003e\n \u003cp\u003e\u0026bull; Usual outpatient rehabilitation services for stroke plus six months of virtual coordinated interprofessional care delivery\u003c/p\u003e\n \u003cp\u003e\u0026bull; Monthly team consensus meeting\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026bull; Medical management\u003c/p\u003e\n \u003cp\u003e\u0026bull; Medication reconciliation\u003c/p\u003e\n \u003cp\u003e\u0026bull; Preventive care\u003c/p\u003e\n \u003cp\u003e\u0026bull; Psychological/social management strategies\u003c/p\u003e\n \u003cp\u003e\u0026bull; Patient empowerment\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026bull; Online resources for patient empowerment\u003c/p\u003e\n \u003cp\u003e\u0026bull; Phone/video visits\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" align=\"left\"\u003e\n \u003cp\u003eIn 6 months of intervention implementation for 44 patients:\u003c/p\u003e\n \u003cp\u003e\u0026bull; No significant change compared to usual group in readmission risk\u003c/p\u003e\n \u003cp\u003e\u0026bull; Improved physical functioning, self-management and patient care experience without increasing total healthcare expenditure\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"7\" align=\"left\"\u003e\n \u003cp\u003eDementia and memory\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"1\" align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"3\" align=\"left\"\u003e\n \u003cp\u003eIntegrated Memory Care Clinic [85] into PCMH\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" rowspan=\"3\" align=\"left\"\u003e\n \u003cp\u003e\u0026bull; Specialized APRNs\u003c/p\u003e\n \u003cp\u003e\u0026bull; RNs\u003c/p\u003e\n \u003cp\u003e\u0026bull; SW\u003c/p\u003e\n \u003cp\u003e\u0026bull; Patient care coordinators\u003c/p\u003e\n \u003cp\u003e\u0026bull; Geriatric psychiatrist\u003c/p\u003e\n \u003cp\u003e\u0026bull; Licensed counselor\u003c/p\u003e\n \u003cp\u003e\u0026bull; Psychiatric home health providers\u003c/p\u003e\n \u003cp\u003e\u0026bull; Pharmacist\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"3\" align=\"left\"\u003e\n \u003cp\u003e\u0026bull; First-line APRN evaluation of referred patients diagnosed with MCI or dementia\u003c/p\u003e\n \u003cp\u003e\u0026bull; APRN collaboration and consultation with neurologist, geriatric or other specialties\u003c/p\u003e\n \u003cp\u003e\u0026bull; Structured team meetings\u003c/p\u003e\n \u003cp\u003e\u0026bull; Shared decision making and determining care goals\u003c/p\u003e\n \u003cp\u003e\u0026bull; Scheduled appointments for care continuity\u003c/p\u003e\n \u003cp\u003e\u0026bull; Available on-call APRN contact for inquiries\u003c/p\u003e\n \u003cp\u003e\u0026bull; Accountability for simultaneous primary care management\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"3\" align=\"left\"\u003e\n \u003cp\u003e\u0026bull; Primary care\u003c/p\u003e\n \u003cp\u003e\u0026bull; Dementia medical management\u003c/p\u003e\n \u003cp\u003e\u0026bull; Psychological and emotional evaluation every 6 months\u003c/p\u003e\n \u003cp\u003e\u0026bull; Annual cognitive testing\u003c/p\u003e\n \u003cp\u003e\u0026bull; Social management strategies\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"3\" align=\"left\"\u003e\n \u003cp\u003e\u0026bull; Community collaboration with support groups including Area Agencies on Aging, Alzheimer\u0026rsquo;s Association and in-house support services\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" align=\"left\"\u003e\n \u003cp\u003eIn 1 year of implementation and caring for 139 patients:\u003c/p\u003e\n \u003cp\u003e\u0026bull; Reduced monthly ambulatory-sensitive hospital admissions (6.7\u0026ndash;0.8%) in the second of year\u003c/p\u003e\n \u003cp\u003e\u0026bull; No significant improvement in neuropsychiatric symptom severity\u003c/p\u003e\n \u003cp\u003e\u0026bull; Increased involvement in community-based services [85]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" align=\"left\"\u003e\n \u003cp\u003eWithin 9 months of implementation:\u003c/p\u003e\n \u003cp\u003e\u0026bull; Decreased symptom severity of patient\u003c/p\u003e\n \u003cp\u003e\u0026bull; Decreased caregivers distress [86]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" align=\"left\"\u003e\n \u003cp\u003eWith one year of care delivery:\u003c/p\u003e\n \u003cp\u003e\u0026bull; Sense of belonging in caregivers [87]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSpecialized Senior Clinic [101]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" align=\"left\"\u003e\n \u003cp\u003e\u0026bull; Geriatrician\u003c/p\u003e\n \u003cp\u003e\u0026bull; Geriatric psychiatrist\u003c/p\u003e\n \u003cp\u003e\u0026bull; Occupational therapist\u003c/p\u003e\n \u003cp\u003e\u0026bull; Physiotherapist\u003c/p\u003e\n \u003cp\u003e\u0026bull; SW\u003c/p\u003e\n \u003cp\u003e\u0026bull; Patient care coordinator\u003c/p\u003e\n \u003cp\u003e\u0026bull; RN\u003c/p\u003e\n \u003cp\u003e\u0026bull; Pharmacist\u003c/p\u003e\n \u003cp\u003e\u0026bull; Dietician\u003c/p\u003e\n \u003cp\u003e\u0026bull; Clerk\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026bull; Screening and triage of PCP referred patients with memory/cognition change by patient care coordinator\u003c/p\u003e\n \u003cp\u003e\u0026bull; Comprehensive geriatric evaluation and interprofessional health planning with client/family\u003c/p\u003e\n \u003cp\u003e\u0026bull; Follow-up with the clinic as required\u003c/p\u003e\n \u003cp\u003e\u0026bull; Long-term collaboration with community PCPs\u003c/p\u003e\n \u003cp\u003e\u0026bull; Patient self-management programs\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026bull; Dementia medical management\u003c/p\u003e\n \u003cp\u003e\u0026bull; Nutritional planning\u003c/p\u003e\n \u003cp\u003e\u0026bull; Physical therapy\u003c/p\u003e\n \u003cp\u003e\u0026bull; Occupational therapy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026bull; Collaboration with community agencies including Alzheimer Society and in-house support services\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" align=\"left\"\u003e\n \u003cp\u003eIn one year of implementation and with ~\u0026thinsp;19000 visits:\u003c/p\u003e\n \u003cp\u003e\u0026bull; High level of satisfaction with the care model among both patients and care team\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"8\" align=\"left\"\u003e\n \u003cp\u003eFracture\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eFracture Liaison Service (FLS) into PCMH [88, 89]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" align=\"left\"\u003e\n \u003cp\u003e\u0026bull; Primary care physician\u003c/p\u003e\n \u003cp\u003e\u0026bull; Orthopedic surgeon\u003c/p\u003e\n \u003cp\u003e\u0026bull; Physician assistant\u003c/p\u003e\n \u003cp\u003e\u0026bull; Clinical pharmacist practitioner\u003c/p\u003e\n \u003cp\u003e\u0026bull; Patient care coordinator\u003c/p\u003e\n \u003cp\u003e\u0026bull; Nurse practitioner\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026bull; Proactive selection of patients with fragility fracture\u003c/p\u003e\n \u003cp\u003e\u0026bull; Appropriate testing and treatment\u003c/p\u003e\n \u003cp\u003e\u0026bull; Coordinated care with PCPs\u003c/p\u003e\n \u003cp\u003e\u0026bull; Long-term care partnership\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026bull; Transitional care\u003c/p\u003e\n \u003cp\u003e\u0026bull; Primary care\u003c/p\u003e\n \u003cp\u003e\u0026bull; Medical management\u003c/p\u003e\n \u003cp\u003e\u0026bull; Preventive care\u003c/p\u003e\n \u003cp\u003e\u0026bull; Patient education\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd colspan=\"2\" align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"8\" align=\"left\"\u003e\n \u003cp\u003eKidney diseases\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePCMH for Kidney Diseases (PCMH-KD) [84]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" align=\"left\"\u003e\n \u003cp\u003e\u0026bull; Nephrologist\u003c/p\u003e\n \u003cp\u003e\u0026bull; Dialysis nurse\u003c/p\u003e\n \u003cp\u003e\u0026bull; Primary care physician\u003c/p\u003e\n \u003cp\u003e\u0026bull; Nurse coordinator\u003c/p\u003e\n \u003cp\u003e\u0026bull; Community health worker\u003c/p\u003e\n \u003cp\u003e\u0026bull; Dietician\u003c/p\u003e\n \u003cp\u003e\u0026bull; SW\u003c/p\u003e\n \u003cp\u003e\u0026bull; Pharmacist\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026bull; Initial assessment by internist and primary care provision within the framework of dialysis care\u003c/p\u003e\n \u003cp\u003e\u0026bull; Weekly comprehensive, multidisciplinary team care management directed by patients\u0026rsquo; needs\u003c/p\u003e\n \u003cp\u003e\u0026bull; Regular continued hemodialysis in dialysis unit\u003c/p\u003e\n \u003cp\u003e\u0026bull; Monthly consensus meeting\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026bull; Medical management\u003c/p\u003e\n \u003cp\u003e\u0026bull; Primary care\u003c/p\u003e\n \u003cp\u003e\u0026bull; Hemodialysis\u003c/p\u003e\n \u003cp\u003e\u0026bull; Nutritional planning\u003c/p\u003e\n \u003cp\u003e\u0026bull; Patient education\u003c/p\u003e\n \u003cp\u003e\u0026bull; Medication review\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026bull; Link to community resources\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" align=\"left\"\u003e\n \u003cp\u003eWith 18 months of implementation and covering 175 patients:\u003c/p\u003e\n \u003cp\u003e\u0026bull; Decreased ED visits and admissions\u003c/p\u003e\n \u003cp\u003e\u0026bull; Improved life quality of patients [110]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePopulation Health Value - Chronic Kidney Disease (PHV-CKD) initiative [83]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" align=\"left\"\u003e\n \u003cp\u003e\u0026bull; Nephrologist\u003c/p\u003e\n \u003cp\u003e\u0026bull; Interventional radiologist\u003c/p\u003e\n \u003cp\u003e\u0026bull; Primary care physician\u003c/p\u003e\n \u003cp\u003e\u0026bull; Patient care coordinators\u003c/p\u003e\n \u003cp\u003e\u0026bull; SW\u003c/p\u003e\n \u003cp\u003e\u0026bull; Pharmacist\u003c/p\u003e\n \u003cp\u003e\u0026bull; RN\u003c/p\u003e\n \u003cp\u003e\u0026bull; Nurse case manager\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026bull; Proactive selection of high risk complex CKD 4\u0026ndash;5 patient\u003c/p\u003e\n \u003cp\u003e\u0026bull; Initial assessment and risk stratification\u003c/p\u003e\n \u003cp\u003e\u0026bull; Coordinated care by a multidisciplinary, interprofessional team through patient-centered communication\u003c/p\u003e\n \u003cp\u003e\u0026bull; Establishment of an aligned system-wide care pathway\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026bull; Primary care\u003c/p\u003e\n \u003cp\u003e\u0026bull; Preventive care\u003c/p\u003e\n \u003cp\u003e\u0026bull; CKD management\u003c/p\u003e\n \u003cp\u003e\u0026bull; Social/behavioral management strategies\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026bull; Collaboration with community resources\u003c/p\u003e\n \u003cp\u003e\u0026bull; Available telephone contact with RN/SW for questions\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" align=\"left\"\u003e\n \u003cp\u003eFollowing one year of initiative implementation and covering\u0026thinsp;~\u0026thinsp;1450 patients:\u003c/p\u003e\n \u003cp\u003e\u0026bull; Reduced monthly hospital admissions by 3.4% and ED visits by 2.6% relative to pre-implementation\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"8\" align=\"left\"\u003e\n \u003cp\u003eMedication reconciliation and polypharmacy\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMedication Management Program [102] into PCMH\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" align=\"left\"\u003e\n \u003cp\u003e\u0026bull; Pharmacist\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026bull; Pharmacist embedded in PCMH core team\u003c/p\u003e\n \u003cp\u003e\u0026bull; Secondary referred from other team members or if the patient had asked\u003c/p\u003e\n \u003cp\u003e\u0026bull; Coordinated medication adjustment and counseling\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026bull; Management of medication-related issues\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026bull; Online messaging or phone encounters\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" align=\"left\"\u003e\n \u003cp\u003eBy enrolling\u0026thinsp;~\u0026thinsp;280 patients in the initiative:\u003c/p\u003e\n \u003cp\u003e\u0026bull; Significant decrease in hospital admissions relative to\u003c/p\u003e\n \u003cp\u003e\u0026bull; Increase in physician office visits\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"8\" align=\"left\"\u003e\n \u003cp\u003eLow back pain\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eCollaborative Care for Older Adults [125]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" align=\"left\"\u003e\n \u003cp\u003e\u0026bull; Family medicine physician\u003c/p\u003e\n \u003cp\u003e\u0026bull; Chiropractor\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026bull; Inclusion of older adults with moderate severity subacute/chronic low back pain\u003c/p\u003e\n \u003cp\u003e\u0026bull; Focused evaluation of patient and development of individualized medical management and referrals if needed\u003c/p\u003e\n \u003cp\u003e\u0026bull; 12 weeks of individualized chiropractic care including mobilization and manipulative therapies and exercises (Dual Care)\u003c/p\u003e\n \u003cp\u003e\u0026bull; Enhanced interdisciplinary and collaborative care for those receiving Shared Care\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026bull; Chiropractic services\u003c/p\u003e\n \u003cp\u003e\u0026bull; Medical management\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026bull; In-home exercises\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" align=\"left\"\u003e\n \u003cp\u003eWith twelve weeks of trial initiation:\u003c/p\u003e\n \u003cp\u003e\u0026bull; Both usual care group and intervention groups experienced improvement in their pain intensity and disability score but no significant between-group differences noted\u003c/p\u003e\n \u003cp\u003e\u0026bull; Higher care satisfaction, quality of life and perceived improvement in intervention groups [15]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"8\" align=\"left\"\u003e\n \u003cp\u003eFall\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eFall Prevention Initiative [58] into Annual Wellness Visits\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" align=\"left\"\u003e\n \u003cp\u003e\u0026bull; RNs\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026bull; Identification of at-risk patient with targeted questions, tests and home safety checklist\u003c/p\u003e\n \u003cp\u003e\u0026bull; Development of individualized plan of care, referrals, referral, assistive equipment and home safety interventions as needed based on guidelines and patient preferences\u003c/p\u003e\n \u003cp\u003e\u0026bull; 2 week follow up to evaluate patient adherence and potential barriers to plan\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026bull; Primary and preventive care\u003c/p\u003e\n \u003cp\u003e\u0026bull; Patient education\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026bull; Home safety assessment\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" align=\"left\"\u003e\n \u003cp\u003eOut of 522 patients in Annual Wellness Visits, 21% screened positive for elevated fall risk with 74% willing to receive personalized care strategy. Follow-up call showed 74% adherence for gait/strength/balance interventions and 67% adherence for home safety interventions.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eStrategies to Reduce Injuries and Develop Confidence in Elders (STRIDE) [100]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" align=\"left\"\u003e\n \u003cp\u003e\u0026bull; Trained nurses\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026bull; Identification of high fall risk patients with targeted questions\u003c/p\u003e\n \u003cp\u003e\u0026bull; Comprehensive risk stratification by evaluation of gait/balance/strength, vision, home safety, osteoporosis and vitamin D\u003c/p\u003e\n \u003cp\u003e\u0026bull; Development of individualized care strategy and referrals if needed\u003c/p\u003e\n \u003cp\u003e\u0026bull; Follow-up and annual risk reassessment\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026bull; Primary and preventive care\u003c/p\u003e\n \u003cp\u003e\u0026bull; Patient education\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026bull; Access to community resources including exercise programs\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" align=\"left\"\u003e\n \u003cp\u003eIntervention being implemented in 86 primary care practices showed:\u003c/p\u003e\n \u003cp\u003e\u0026bull; No significant difference in serious fall injury events per 100 person-years in intervention group\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"8\" align=\"left\"\u003e\n \u003cp\u003eFrailty\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eFrailty Screening and Geriatric Assessment Service in outpatient nephrology center [126]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" align=\"left\"\u003e\n \u003cp\u003e\u0026bull; Physician\u003c/p\u003e\n \u003cp\u003e\u0026bull; Occupational therapist\u003c/p\u003e\n \u003cp\u003e\u0026bull; Dialysis staff\u003c/p\u003e\n \u003cp\u003e\u0026bull; Clinical nurse specialist\u003c/p\u003e\n \u003cp\u003e\u0026bull; Dietician\u003c/p\u003e\n \u003cp\u003e\u0026bull; Psychologist\u003c/p\u003e\n \u003cp\u003e\u0026bull; SW\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026bull; Frailty, psychological and functional screening of nephrology patients using standard tools\u003c/p\u003e\n \u003cp\u003e\u0026bull; Comprehensive geriatric assessment by occupational therapist\u003c/p\u003e\n \u003cp\u003e\u0026bull; Multidisciplinary team meeting to implement care plan based on patient\u0026rsquo;s need\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026bull; Medical management\u003c/p\u003e\n \u003cp\u003e\u0026bull; Dialysis\u003c/p\u003e\n \u003cp\u003e\u0026bull; Preventive care\u003c/p\u003e\n \u003cp\u003e\u0026bull; Nutritional planning\u003c/p\u003e\n \u003cp\u003e\u0026bull; Medication management\u003c/p\u003e\n \u003cp\u003e\u0026bull; Social and psychological management strategies\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd colspan=\"2\" align=\"left\"\u003e\n \u003cp\u003eOf 450 patients in nephrology center, 33% screened positive for frail with 35 patients receiving comprehensive geriatric assessment and multidisciplinary planning.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"8\" align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eCondition-Specific Patient-Centered Specialty Clinics\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eModel\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" align=\"left\"\u003e\n \u003cp\u003eTeam members\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eCare attributes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eIn-center services\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eOut-of-center services\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" align=\"left\"\u003e\n \u003cp\u003eOutcomes\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"8\" align=\"left\"\u003e\n \u003cp\u003eDementia and memory\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eComprehensive Memory Center [62]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" align=\"left\"\u003e\n \u003cp\u003e\u0026bull; Behavioral neurologist: 1\u003c/p\u003e\n \u003cp\u003e\u0026bull; General neurologist: 1\u003c/p\u003e\n \u003cp\u003e\u0026bull; Geriatric psychiatrist: 1\u003c/p\u003e\n \u003cp\u003e\u0026bull; Neuropsychologist: 2\u003c/p\u003e\n \u003cp\u003e\u0026bull; Advanced nurse practitioner: 1\u003c/p\u003e\n \u003cp\u003e\u0026bull; RN: 1\u003c/p\u003e\n \u003cp\u003e\u0026bull; SW: 3\u003c/p\u003e\n \u003cp\u003e\u0026bull; Speech language pathologist (SLP): 1\u003c/p\u003e\n \u003cp\u003e\u0026bull; Medical assistant: 1\u003c/p\u003e\n \u003cp\u003e\u0026bull; Pharmacist: 1\u003c/p\u003e\n \u003cp\u003e\u0026bull; Psychometrist: 2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026bull; Initial assessment and diagnostic evaluation by physician/neuropsychologist, APN and SW\u003c/p\u003e\n \u003cp\u003e\u0026bull; Onsite diagnostic facilities\u003c/p\u003e\n \u003cp\u003e\u0026bull; Co-located visits of multiple specialties\u003c/p\u003e\n \u003cp\u003e\u0026bull; Bi-weekly interprofessional joint visits throughout the care\u003c/p\u003e\n \u003cp\u003e\u0026bull; Weekly consensus meetings of healthcare team for care plan decision\u003c/p\u003e\n \u003cp\u003e\u0026bull; Discussion about care plan with patient/carer dyad during feedback appointment\u003c/p\u003e\n \u003cp\u003e\u0026bull; Post-diagnosis support visits for care continuity\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026bull; Medical management\u003c/p\u003e\n \u003cp\u003e\u0026bull; Psychological evaluation\u003c/p\u003e\n \u003cp\u003e\u0026bull; Social/behavioral management strategies\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026bull; In-home support: counselling by SW, cognitive communication therapy by SLP and in-home coordination of care\u003c/p\u003e\n \u003cp\u003e\u0026bull; Community collaboration with local support groups and agencies\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" align=\"left\"\u003e\n \u003cp\u003eIn 3.5 years of implementation and caring for ~\u0026thinsp;750 patients:\u003c/p\u003e\n \u003cp\u003e\u0026bull; Reduced initial visit to diagnosis interval\u003c/p\u003e\n \u003cp\u003e\u0026bull; Patient/carer dyad satisfied by the model\u003c/p\u003e\n \u003cp\u003e\u0026bull; Improved effective interprofessional team dynamics [62]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMultidimensional Interdisciplinary Rehabilitation in Dementia (MIDRED) [127]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" align=\"left\"\u003e\n \u003cp\u003e\u0026bull; Neuropsychologists\u003c/p\u003e\n \u003cp\u003e\u0026bull; Physicians\u003c/p\u003e\n \u003cp\u003e\u0026bull; Nurses\u003c/p\u003e\n \u003cp\u003e\u0026bull; Physical therapist\u003c/p\u003e\n \u003cp\u003e\u0026bull; Occupational therapist\u003c/p\u003e\n \u003cp\u003e\u0026bull; Dietician\u003c/p\u003e\n \u003cp\u003e\u0026bull; SW\u003c/p\u003e\n \u003cp\u003e\u0026bull; Pharmacist\u003c/p\u003e\n \u003cp\u003e\u0026bull; Dental hygienist\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026bull; Initial comprehensive assessment of dementia confirmed patient\u003c/p\u003e\n \u003cp\u003e\u0026bull; Multidisciplinary individualized rehabilitation goal setting according to patient\u0026rsquo;s problems and needs\u003c/p\u003e\n \u003cp\u003e\u0026bull; Rehabilitation program for sixteen weeks\u003c/p\u003e\n \u003cp\u003e\u0026bull; Caregiver group education and discussion\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026bull; Rehabilitation\u003c/p\u003e\n \u003cp\u003e\u0026bull; Caregiver education\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026bull; Link to community services\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" align=\"left\"\u003e\n \u003cp\u003eWith 4\u0026ndash;5 months of intervention implementation and inclusion of 16 patients, they felt empowered and seen, gained new insights and incentives, and experienced togetherness.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"8\" align=\"left\"\u003e\n \u003cp\u003eRheumatology\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eLifelong Treatment Model for Rheumatoid Arthritis [128]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" align=\"left\"\u003e\n \u003cp\u003e\u0026bull; Rheumatologist\u003c/p\u003e\n \u003cp\u003e\u0026bull; Nurse\u003c/p\u003e\n \u003cp\u003e\u0026bull; Physiotherapist\u003c/p\u003e\n \u003cp\u003e\u0026bull; Occupational therapeutic\u003c/p\u003e\n \u003cp\u003e\u0026bull; Pharmacist\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026bull; Rheumatologist visit of referred patient with undiagnosed symptoms from PCP\u003c/p\u003e\n \u003cp\u003e\u0026bull; Shared decision making and multidisciplinary patient-centered treatment until remission\u003c/p\u003e\n \u003cp\u003e\u0026bull; Patient empowerment and self-monitoring program\u003c/p\u003e\n \u003cp\u003e\u0026bull; Health maintenance through PCP and tele-health monitored by rheumatology-specialized nurses\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026bull; Medical management\u003c/p\u003e\n \u003cp\u003e\u0026bull; Patient empowerment and self-monitoring program\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026bull; Tele-Health\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"8\" align=\"left\"\u003e\n \u003cp\u003eCancer\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eProstate Cancer Unit [80]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" align=\"left\"\u003e\n \u003cp\u003e\u0026bull; Clinical director\u003c/p\u003e\n \u003cp\u003e\u0026bull; Uropathologist:1\u0026ndash;2\u003c/p\u003e\n \u003cp\u003e\u0026bull; Urologist: \u0026ge; 2\u003c/p\u003e\n \u003cp\u003e\u0026bull; Radiation oncologist: \u0026ge; 2\u003c/p\u003e\n \u003cp\u003e\u0026bull; Medical oncologist: \u0026ge; 1\u003c/p\u003e\n \u003cp\u003e\u0026bull; Nurse specialist: \u0026ge; 1\u003c/p\u003e\n \u003cp\u003e\u0026bull; Data managers\u003c/p\u003e\n \u003cp\u003e\u0026bull; Documentation specialist\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026bull; Recruiting individuals with prostate cancer in all stages\u003c/p\u003e\n \u003cp\u003e\u0026bull; Ideally co-located buildings\u003c/p\u003e\n \u003cp\u003e\u0026bull; Protocol-based single multidisciplinary team care and regular follow up\u003c/p\u003e\n \u003cp\u003e\u0026bull; Collaboration with out-side adjuvant and palliative therapies under its direction\u003c/p\u003e\n \u003cp\u003e\u0026bull; Rehabilitation under its direction\u003c/p\u003e\n \u003cp\u003e\u0026bull; Minimum annual audit meeting for evaluation of quality indicators and protocols\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026bull; Medical management\u003c/p\u003e\n \u003cp\u003e\u0026bull; Observational strategies\u003c/p\u003e\n \u003cp\u003e\u0026bull; Chemotherapy\u003c/p\u003e\n \u003cp\u003e\u0026bull; Hormonal therapy\u003c/p\u003e\n \u003cp\u003e\u0026bull; Radiation therapy and brachytherapy\u003c/p\u003e\n \u003cp\u003e\u0026bull; Surgery\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026bull; Access to different professional services including radiologist, medical physicist, physiotherapist, sexologist, adjunctive, palliative and psychological therapies\u003c/p\u003e\n \u003cp\u003e\u0026bull; Collaboration with advocacy group associations such as Europa Uomo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eOncology care with integrated supportive team based on PACT model [57]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" align=\"left\"\u003e\n \u003cp\u003e\u0026bull; Attending medical oncologists\u003c/p\u003e\n \u003cp\u003e\u0026bull; Medical oncology fellows\u003c/p\u003e\n \u003cp\u003e\u0026bull; Psychology interns\u003c/p\u003e\n \u003cp\u003e\u0026bull; Palliative care physician\u003c/p\u003e\n \u003cp\u003e\u0026bull; Oncology nursing staff\u003c/p\u003e\n \u003cp\u003e\u0026bull; Patient care coordinator\u003c/p\u003e\n \u003cp\u003e\u0026bull; SW\u003c/p\u003e\n \u003cp\u003e\u0026bull; Clinic clerks\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026bull; Screening and risk stratification of newly diagnosed patients at beginning and every three months or with change of disease course via distress tools\u003c/p\u003e\n \u003cp\u003e\u0026bull; Multidisciplinary problem solving according to patient\u0026rsquo;s preferences and referrals to corresponding specialists or supportive care services\u003c/p\u003e\n \u003cp\u003e\u0026bull; Patient education\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026bull; Oncology care\u003c/p\u003e\n \u003cp\u003e\u0026bull; Psychological management strategies\u003c/p\u003e\n \u003cp\u003e\u0026bull; Palliative care\u003c/p\u003e\n \u003cp\u003e\u0026bull; Adjacent same-personnel chemo-infusion clinic\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026bull; Access to support services including in-home services, dietician, physical and occupational therapist and mental health programs\u003c/p\u003e\n \u003cp\u003e\u0026bull; Partnership to local support groups including Gilda\u0026rsquo;s Club and the Cancer Support Center\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" align=\"left\"\u003e\n \u003cp\u003eOver two years and half of program initiation and ~\u0026thinsp;1000 screenings occurred, followed by corresponding care process.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"8\" align=\"left\"\u003e\n \u003cp\u003ePsychiatry\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eEnhancing Quality in Psychiatry with Psychiatrists (EQUIPP) [129]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" align=\"left\"\u003e\n \u003cp\u003e\u0026bull; Psychiatrist\u003c/p\u003e\n \u003cp\u003e\u0026bull; Clinical pharmacist\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026bull; Comprehensive medication assessment and review of medication-related issues by pharmacist\u003c/p\u003e\n \u003cp\u003e\u0026bull; Development of care plan according to patient\u0026rsquo;s preferences and collaboration with physician\u003c/p\u003e\n \u003cp\u003e\u0026bull; Patient/carer education\u003c/p\u003e\n \u003cp\u003e\u0026bull; Care surveillance and medication evaluation by pharmacist for six months\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026bull; Medication management\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026bull; Follow-up by phone\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" align=\"left\"\u003e\n \u003cp\u003eWithin six months of implementation and inclusion of 26 patients:\u003c/p\u003e\n \u003cp\u003e\u0026bull; No change in the total number of medication related issues\u003c/p\u003e\n \u003cp\u003e\u0026bull; No difference in healthcare utilization or transfers to higher care levels\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n \u003c/div\u003e\n\u003c/div\u003e\n\u003cdiv class=\"Section2\"\u003e\u0026nbsp;\u003c/div\u003e\n\u003cdiv class=\"Section2\"\u003e\u003cstrong\u003eA) Primary Healthcare Models\u003c/strong\u003e\u003cbr\u003e\n \u003cp\u003ePrimary healthcare models focus on delivering comprehensive and coordinated services at the first point of contact, aiming to address the general health needs of older adults while integrating behavioral health, chronic disease management, and preventive care. Notable models in this category include PCMH [64, 65], Comprehensive Primary Care (CPC) initiative [66], and Guided Care [67]. Among these, PCMH stands out as a widely adopted model in the US, implemented in over 10,000 primary care practices by more than 50,000 clinicians, adhering to standards set by the National Committee for Quality Assurance (NCQA) [68]. This model emphasizes a holistic, team-based approach that manages patients\u0026apos; health needs, delivers accessible services, enhances quality \u0026amp; safety, and redesigns traditional care structures. Its interdisciplinary teams typically include physicians, nurses, behavioral health professionals, case managers, pharmacists, social workers, and nutritionists [65].\u003c/p\u003e\n \u003cp\u003eThe US Department of Veterans Affairs introduced the Patient-Aligned Care Team (PACT) in 2010, followed by the GeriPACT model specifically for older veterans, as extensions of the PCMH framework [69, 70]. The adaptation of PCMH and PACT for elderly outpatient care has demonstrated significant benefits, including improved care quality, reduced emergency department visits, and more efficient care delivery [71\u0026ndash;74]. However, studies show mixed results regarding their impact on healthcare expenditures, with some reporting cost savings [75] and others finding no significant change [14, 72]. Building on PCMH principles, the CPC initiative and its successor, CPC Plus (CPC+), were introduced by the Centers for Medicare \u0026amp; Medicaid Services (CMS) to incorporate multi-payer payment reform and data-driven interventions. Over four years, CPC achieved improvements in care delivery, slower growth in ED visits, and better patient experiences, although it did not significantly reduce healthcare utilization [76, 77]. Similarly, CPC\u0026thinsp;+\u0026thinsp;demonstrated reduced ED visits from the first year onward and decreased hospital admissions in later years, but with no discernible change in total expenditures over five years [78].\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eB) Specialized Healthcare Models\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eSpecialized care models, on the other hand, provide care for specific conditions, often involving multidisciplinary teams with expertise tailored to a particular disease or health issue while managing physical, emotional or psychological issues arising from the disease. PCC-aligned specialty units such as Prostate Cancer Unit and Breast Cancer Model have shown success in structuring cancer care across the patient journey and improve care coordination [79\u0026ndash;81]. Similarly, Comprehensive Memory Center, which provide focused and specialized services to patients living with dementia, also has demonstrated promising results in improving disease diagnosis and care satisfaction, and strengthening interprofessional teamwork dynamics [62].\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eC) Integrated Healthcare Models\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eLastly, integrated care models expand on primary care frameworks by incorporating specialized services tailored to the needs of a targeted populations, and aim to enhance care continuity and outcomes. Transitional care programs integrated into primary care, such as the Transitional Care Manager embedded within the PCMH, have demonstrated notable benefits. Over six months of this integration, it resulted in resource savings, fewer ED visits, and hospitalizations, alongside improved patient experiences [82]. Likewise, integrated models such as PCMH-KD and Population Health Value - Chronic Kidney Disease (PHV-CKD), designed for patients with end-stage renal disease, reported reductions in ED visits and hospital admissions [83, 84]. Integrated Memory Care Clinic, as another integrated model of care tailored for patients with mild cognitive impairment or dementia, combined primary care with specialized dementia management. This model achieved promising outcomes, including reduced ambulatory-sensitive hospital admissions, decreased symptom severity, and alleviated caregiver distress [85, 86]. Caregivers also valued the dedication of staff and access to after-hours services, which enhanced overall satisfaction with care [87].\u003c/p\u003e\n \u003cp\u003eOther integrated programs address gaps in follow-up care and compliance among vulnerable populations. For example, older adults with osteoporotic fractures often exhibit poor follow-up, but integrating a Fracture Liaison Service within PCMH frameworks has shown potential for addressing these challenges effectively [88, 89]. Furthermore, interventions like the Behavioral Health and Chronic Illness Care model, targeting primary care and selected chronic conditions, have also demonstrated strong positive effects, such as improved acceptance of care and reduced ED visits, though without significant changes in Medicare expenditures [90].\u003c/p\u003e\n\u003c/div\u003e"},{"header":"4. Discussion","content":"\u003cp\u003eWe aimed to explore how PCC is conceptualized and implemented in elderly outpatient setting. By systematically mapping the diverse dimensions of PCC, identifying stakeholder viewpoints, examining barriers to its adoption, and assessing the structure, processes, and outcomes of various practical PCC models, our study contributes to understanding how PCC can be integrated into existing healthcare systems, especially in resource-constrained settings.\u003c/p\u003e \u003cp\u003e \u003cem\u003e“Nothing about me without me\u003c/em\u003e,\u003cem\u003e”\u003c/em\u003e a phrase by Valerie Billingham, captures one of the most resonant principles of partnering with patients in their care plans [91]. This statement aligns deeply with PCC concept and emphasizes transforming patients from passive recipients into active participants. Shared decision-making, referred to as the “pinnacle” of PCC [92], encourages healthcare providers to step back from their paternalistic, directive role and adopt a partnership-based approach. By asking not just \u003cem\u003e“What is the matter?”\u003c/em\u003e but also \u003cem\u003e“What matters to you?”\u003c/em\u003e providers call for a care dynamic grounded in respect for the patient’s values, needs and preferences, while also sharing responsibility for outcomes and experiences throughout the care continuum [4, 36, 92]. From the studies reviewed, it became evident that PCC delivery, particularly for older adults, is not merely a clinical framework but a culture that needs to be cultivated system-wide. From the patient’s first interaction with the healthcare system to follow-ups and feedback mechanisms, every touchpoint is an opportunity to embody PCC principles. This includes the center organizational structure, attitudes of healthcare providers and staff, care plan development processes, care pathways, community collaborations and local support groups, payment structures and program evaluations [1, 16, 25, 28, 29, 37, 77].\u003c/p\u003e \u003cp\u003eUnderstanding and bridging the perspectives of patients and providers is central to the successful implementation of PCC. Our scoping review showed that although patients and providers shared the common goal of achieving high-quality, personalized care plans, their perspectives on what PCC looks like differed in emphasis. Providers tended to focus on systemic efficiency, teamwork, and care coordination [16, 38–43, 51, 52], while patients prioritized accessibility, emotional connection, trust, and the relational aspects of care delivery [39, 40, 43, 44, 46, 47, 49, 50, 53]. Effective PCC must go beyond addressing medical conditions; it requires healthcare providers to see the person beyond their diagnosis, understand their life beyond hospital walls and incorporate life stories into care plan development [41, 47, 53]. Patient experience emerges as a critical measure to of PCC and should be continuously monitored to shape care trajectory. For older adults, care is rarely a solitary endeavor. They often involve family members or trusted friends in medical decision-making and health management [56]. This partnership underscores the importance of integrating not only the patient’s but also their support network’s perspectives into the care process [28]. Patient and Family Advisory Councils, which includes patients and families, directors, healthcare providers and staff, can facilitate this integration and co-create care models tailored to elderly unique values and preferences [93].\u003c/p\u003e \u003cp\u003eThe implementation of PCC faces significant barriers, particularly in resource-constrained settings. From our review, the most frequently reported challenges included infrastructural obstacles, financial and human resource limitations, transportation barriers and lack of time [16, 29, 40–42, 46, 49–52, 55, 57–61]. Addressing these barriers requires a multi-faceted approach, combining leadership support, financial innovation and strategic policy changes. Strong commitment from top leadership within health systems is pivotal in driving the cultural and structural transformation necessary for PCC [94]. Leaders can champion PCC by aligning organizational priorities, providing clear mandates for PCC implementation, being open to new ideas, forming dedicated PCC committees and allocating dedicated resources [95]. Leadership training and accreditation programs, such as those offered by NCQA, can also incentivize widespread adoptation of PCC practices [95]. Financially, incorporating non-profit structures [16] and securing private funding such as through philanthropic investments [96] can provide supplementary resources for launching PCC programs. Expanded insurance coverage and integration into value-based reimbursement systems represent strategic policies to overcome financial barriers [97, 98]. In addition, training healthcare providers on PCC principles has shown to improve adherence to patient-centered practices and enhance care satisfaction [99].\u003c/p\u003e \u003cp\u003e The finding from our scoping review highlighted several practical PCC-aligned models delivering care to elderly patients in outpatient settings. Successful models consistently included multidisciplinary teams, holistic and comprehensive care pathways, active patient engagement mechanisms and robust care coordination and continuity. Majority of models involved collaborations with community-based agencies and social services, which added significant value to patient care delivery [57, 62, 65, 80, 83, 85, 100, 101]. Clinical pharmacist and social workers were often included in the healthcare team. Pharmacists had an integral role in medication reconciliation, addressing medication-related issues, recommending appropriate medications alternatives, and managing polypharmacy [65, 102]. Social workers, also, supported four domains of care: behavioral health management, acting as a case managers, discussing financial challenges and potential barriers to care, and facilitating access to community services [62, 65, 103]. Care coordinators, often as a core team member, played an integral role in improving patients’ outcomes by enhancing interdisciplinary communication, managing care continuity, and optimizing resource use. Nurses, occupational therapists, and social workers frequently functioned as care coordinators in different models of PCC implementation. Moreover, studies have shown that nurses, as primary points of contact with patients, play a central role in implementation of PCC culture. Aside from nurses’ contribution to patient triage, comprehensive geriatric assessments, screening, education and coaching, care coordination, nursing services and referrals, nurse-led PCC models have demonstrated notable success in improving patient adherence, clinical outcomes, and care quality [104–106].\u003c/p\u003e \u003cp\u003e These models collectively demonstrate the potential of PCC interventions to enhance care quality, optimize outcomes, and address systemic challenges in elderly outpatient settings. While cost-effectiveness remains variable, the overall improvements in quality of life and patient satisfaction highlight the value of incorporating PCC into healthcare delivery. The evidence suggests that, when implemented correctly, PCC interventions can enhance outcomes without imposing significant additional healthcare expenses [14, 72, 76, 90, 107], or even yielding savings by reducing unnecessary hospitalizations or emergency visits [75, 82, 83, 108–110].\u003c/p\u003e \u003cp\u003e \u003cb\u003eRecommendations for implementing PCC in LMICs\u003c/b\u003e \u003c/p\u003e \u003cp\u003e Based on insights from PCC concept in elderly outpatient care context, stakeholder viewpoints, identified barriers to the operationalization of PCC at practical levels, and health administration and community medicine experts’ opinions, we developed a PCC framework and provide actionable recommendations for enhancing elderly outpatient care services in LMICs.\u003c/p\u003e \u003cp\u003eIn LMICs like Iran, healthcare systems face significant challenges related to organizational infrastructure, payment structures, financial constraints, fragmented health insurance and information technologies [111]. As identified by our scoping review, these barriers hinder the widespread adoption of PCC. Despite the Ministry of Health's incorporation of hospital accreditation processes since 2012, PCC lacks a clearly defined position in these policies. Additionally, no accreditation standards exist for outpatient clinics or non-surgical centers, with current guidelines only evaluating hospital outpatient departments [112, 113]. Furthermore, clinic visits typically structured as single-physician encounters with little integration of allied health professionals, medical decision dominance by physicians, and an average visit length of less than five minutes in Iran leave no place for actual patient-centeredness [111, 114, 115].\u003c/p\u003e \u003cp\u003eGiven these challenges, we propose that the initial implementation of PCC in Iran should focus on older adults with multimorbidity, who are likely to benefit the most. Multimorbidity is a growing issue in Iran, with conditions such as ischemic heart diseases, stroke, low back pain, neoplasms, and diabetes mellitus being the top five causes of disability-adjusted life years in older population of Iran [116]. Focusing on this population allows for a targeted approach, addressing the most pressing health issues while avoiding the complexities associated with providing universal care across all age groups.\u003c/p\u003e \u003cp\u003eOur seven-dimensional PCC model for elderly outpatient care delivery aligns with global principles of PCC while tailoring its implementation to the Iranian context [Figure 2]. The seven dimensions are:\u003c/p\u003e \u003cp\u003e \u003c/p\u003e\u003col\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eAccess to Care: Ensuring that care is physically and temporally accessible to patients.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eProactive Care: Actively identifying and engaging eligible patients through healthcare systems, such as hospitals or primary care providers rather than waiting for patients to initiate contact.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003ePatient Empowerment: Educating patients to have patient-controlled care and patient-monitored care.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eIntegrated into Care Pathway: Providing specialized care services for select conditions within primary care framework.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eWhole-Person Approach: Addressing the full range of a patient’s context, including physical, mental, social and financial aspects.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eCoordinated Care: Promoting teamwork among healthcare providers and other healthcare centers to deliver comprehensive care.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eShared Decision-Making: Partnering with patients in decisions about their treatment, respecting their preferences and values, and sharing responsibility.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003c/ol\u003e \u003cp\u003e\u003c/p\u003e\u003cp\u003e For the initial phase of implementation in Iran, we propose an integrated healthcare model focusing on the elderly population with two or more of select guideline-based confirmed conditions: ischemic heart diseases, stroke, subacute/chronic low back pain, neoplasms, and diabetes mellitus. This model should blend primary and specialized care, using principles from successful models like the PCMH [65] and Behavioral Health and Chronic Illness Care Intervention [90]. By adapting these models, we can provide holistic care that integrates physical health, mental health, and social support.\u003c/p\u003e \u003cp\u003eOur proposed interdisciplinary team for PCC implementation includes internist, nurses, physical therapist, social worker, occupational therapist, clinical psychologist, dietician, clinical pharmacist, and receptionist/medical informatics.\u003c/p\u003e \u003cp\u003eThe role of the patient care coordinator and educator is critical, and this responsibility should be assigned to nurses. Nurses are well-positioned to provide comprehensive care, educate patients and their families, and ensure care continuity. This model should offer a comprehensive range of services, including preventive care, chronic disease management, medication management, psychological support, social/behavioral health management, frailty and fall risk assessments, physical activity counseling, and nutritional planning.\u003c/p\u003e \u003cp\u003e\u003c/p\u003e"},{"header":"Conclusions and Recommendations","content":"\u003cp\u003eThe integration of comprehensive, preventive and PCC has the potential to enhance both the quality of care and patient satisfaction. To support PCC adoption in Iran and similar LMICs, we recommend:\u003c/p\u003e\u003cp\u003e \u003c/p\u003e\u003cul\u003e \u003cli\u003e \u003cp\u003eAssessing the cost-effectiveness of the proposed PCC model in LMICs.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eLaunching financially sustainable pilot programs focused on older adults with multimorbidity.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eDesigning training programs for healthcare providers on PCC principles and practices.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eEstablishing policy and accreditation frameworks that incentivize PCC adoption and ensure periodic reevaluation\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eCMS\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eCenters for Medicare \u0026amp; Medicaid Services\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eCPC\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eComprehensive primary care\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eJBI\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eJoanna Briggs Institute\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eLMIC: Low- and middle-income countries\u003c/div\u003e \u003cdiv class=\"Description\"\u003e\u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eNCQA\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eNational Committee for Quality Assurance\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003ePACT\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003ePatient-aligned care team\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003ePCC\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003ePatient-centered care\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003ePCMH\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003ePatient-centered medical home\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003ePRISMA-ScR\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003ePreferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003ePRO\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003ePatient-reported outcome\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Declarations","content":" \u003cp\u003e \u003cstrong\u003eEthics Approval and Consent to Participate:\u003c/strong\u003e \u003cp\u003eNot applicable.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eConsent for Publication:\u003c/strong\u003e \u003cp\u003eNot applicable.\u003c/p\u003e \u003c/p\u003e\u003cp\u003e \u003ch2\u003eCompeting Interests:\u003c/h2\u003e \u003cp\u003eAuthors declare no competing interests.\u003c/p\u003e \u003c/p\u003e\u003ch2\u003eFunding:\u003c/h2\u003e \u003cp\u003eNo funding was received for this study.\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eNH, MA, and Ehsan T conceptualized the study and contributed to the design of methodology. Erfan T, AA, and FG were responsible for screening and data extraction. SB and Ehsan T presented and contributed to data interpretation. Erfan T, AA, FG and SB drafted the manuscript. MA and Ehsan T supervised the overall project. All authors critically reviewed and approved the final manuscript.\u003c/p\u003e\u003ch2\u003eAcknowledgements:\u003c/h2\u003e \u003cp\u003eNone.\u003c/p\u003e\u003ch2\u003eData Availability\u003c/h2\u003e\u003cp\u003eData is provided within the manuscript or supplementary information files.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003e Tinetti, M.E., A.D. Naik, and J.A. 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Bower, \u003cem\u003ePatient-centredness: a conceptual framework and review of the empirical literature.\u003c/em\u003e Soc Sci Med, 2000. \u003cb\u003e51\u003c/b\u003e(7): p. 1087\u0026thinsp;\u0026minus;\u0026thinsp;110.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003e Langberg, E.M., L. Dyhr, and A.S. Davidsen, \u003cem\u003eDevelopment of the concept of patient-centredness - A systematic review.\u003c/em\u003e Patient Educ Couns, 2019. \u003cb\u003e102\u003c/b\u003e(7): p. 1228\u0026ndash;1236.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003e Lusk, J.M. and K. 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Ogle, \u003cem\u003eA person-centred lifestyle change intervention model: Working with older people experiencing chronic illness.\u003c/em\u003e International Journal of Nursing Practice, 2012. \u003cb\u003e18\u003c/b\u003e(4): p. 379\u0026ndash;387.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003e Goertz, C.M., et al., \u003cem\u003eCollaborative Care for Older Adults with low back pain by family medicine physicians and doctors of chiropractic (COCOA): study protocol for a randomized controlled trial.\u003c/em\u003e Trials, 2013. \u003cb\u003e14\u003c/b\u003e: p. 18.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003e Nixon, A.C., et al., \u003cem\u003eImplementation of a frailty screening programme and Geriatric Assessment Service in a nephrology centre: a quality improvement project.\u003c/em\u003e J Nephrol, 2021. \u003cb\u003e34\u003c/b\u003e(4): p. 1215\u0026ndash;1224.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003e Sondell, A., et al., \u003cem\u003eExperiences of community-dwelling older people with dementia participating in a person-centred multidimensional interdisciplinary rehabilitation program.\u003c/em\u003e BMC Geriatrics, 2021. \u003cb\u003e21\u003c/b\u003e(1): p. 341.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003e Brkic, A., et al., \u003cem\u003eDecentralizing healthcare in Norway to improve patient-centered outpatient clinic management of rheumatoid arthritis - a conceptual model.\u003c/em\u003e BMC Rheumatol, 2021. \u003cb\u003e5\u003c/b\u003e(1): p. 43.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003e Watson, L.C., et al., \u003cem\u003eEnhancing Quality in Psychiatry with Psychiatrists (EQUIPP)--results from a pilot study.\u003c/em\u003e Am J Geriatr Psychiatry, 2014. \u003cb\u003e22\u003c/b\u003e(9): p. 884-8.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-geriatrics","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bgtc","sideBox":"Learn more about [BMC Geriatrics](http://bmcgeriatr.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bgtc/default.aspx","title":"BMC Geriatrics","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Patient-Centered Care, Elderly, Outpatient, Low and Middle Income Countries, Healthcare Model, Chronic Disease Management, Person-Centered Care, Aged","lastPublishedDoi":"10.21203/rs.3.rs-5882301/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-5882301/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground: \u003c/strong\u003ePatient-centered care (PCC) has emerged as a crucial approach in the healthcare delivery for older adults due to the aging population and the unique challenges they face. Long-term management and patient involvement are particularly relevant in outpatient settings. This scoping review provides a comprehensive overview of existing evidence on PCC for older adults, mapping definitions, elements, stakeholder perspectives, barriers to implementation, and practical models of PCC adoptation. Additionally, it offers actionable recommendations for integrating PCC into healthcare systems in low- and middle-income countries (LMICs).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods: \u003c/strong\u003eA systematic search was conducted in PubMed, Web of Science, Scopus, and Google Scholar on 2 August 2024, with no publication year restrictions, to capture the full range of available evidence. We adhered to the JBI methodology for scoping reviews. Data synthesis involved a descriptive approach with findings contextualized to support the integration of PCC into LMIC healthcare systems.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults: \u003c/strong\u003eFrom an initial pool of 1474 sources, 76 records were included for data extraction. The majority of PCC definitions shared key themes, including partnership with patients in decision-making, a holistic approach to patient care, and coordination across multiple disciplines. The review revealed that while patients and providers shared the goal of achieving high-quality, personalized care, their perspectives on PCC differed. Providers emphasized systemic efficiency, teamwork, and care coordination, whereas patients valued accessibility, emotional connection, trust, and relational aspects of care. Key barriers to implementing PCC included infrastructural challenges, financial and human resource limitations, transportation issues, and time constraints. Successful models of PCC often involved multidisciplinary teams and community-based collaborations, which were particularly effective in managing chronic diseases in elderly patients.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions: \u003c/strong\u003eThis review highlights the potential of PCC in enhancing the quality of care for older adults in outpatient settings. Building on our findings, a phased approach focusing on older adults with multimorbidity is recommended for LMICs like Iran, with an emphasis on integrating both primary and specialized care. Our proposed seven-dimensional PCC model includes access to care, proactive care, patient empowerment, integration into care pathways, a whole-person approach, coordinated care, and shared decision-making, tailored for LMIC contexts to improve care for elderly patients.\u003c/p\u003e","manuscriptTitle":"Exploring patient-centered care delivery in elderly outpatient settings: A scoping review and recommendations for implementation in countries with low and middle income","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-04-03 10:56:38","doi":"10.21203/rs.3.rs-5882301/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-07-11T06:38:56+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-06-26T23:04:44+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"183709266062927406747931416210408159642","date":"2025-06-17T22:27:25+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-04-07T14:25:29+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-04-02T18:07:58+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"173840933220156265644572744755656596662","date":"2025-04-01T10:54:12+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"163696411442681768885624348634817442804","date":"2025-03-31T08:36:37+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-02-18T01:38:48+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-01-28T05:27:58+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-01-25T07:25:51+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-01-25T07:23:53+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Geriatrics","date":"2025-01-22T15:48:41+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-geriatrics","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bgtc","sideBox":"Learn more about [BMC Geriatrics](http://bmcgeriatr.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bgtc/default.aspx","title":"BMC Geriatrics","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"8b75d8f6-1cf0-4c52-900f-6506972a23d1","owner":[],"postedDate":"April 3rd, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-11-24T16:11:21+00:00","versionOfRecord":{"articleIdentity":"rs-5882301","link":"https://doi.org/10.1186/s12877-025-06643-9","journal":{"identity":"bmc-geriatrics","isVorOnly":false,"title":"BMC Geriatrics"},"publishedOn":"2025-11-21 15:58:11","publishedOnDateReadable":"November 21st, 2025"},"versionCreatedAt":"2025-04-03 10:56:38","video":"","vorDoi":"10.1186/s12877-025-06643-9","vorDoiUrl":"https://doi.org/10.1186/s12877-025-06643-9","workflowStages":[]},"version":"v1","identity":"rs-5882301","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-5882301","identity":"rs-5882301","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}