Integrative Models of Care for Healthy Aging in the Elderly: A Narrative Review

Integrative Models of Care for Healthy Aging in the Elderly: A Narrative Review | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Systematic Review Integrative Models of Care for Healthy Aging in the Elderly: A Narrative Review Payton Wolbert, Yousif Gariaqoza, Alexander Forrest, Jyotsna Pandey This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6221967/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background Recent global increases in aging populations have prompted an increased need to provide quality care for older adults, especially older adults who are living with frailty and multiple chronic conditions. A response to this has been implementing innovative and interdisciplinary models of care that focus on the need to enhance older adults’ quality of life and well-being. Several effective multidisciplinary care services have emerged to address the physical, cognitive, and psychosocial needs of older adults that involve integrated approaches. In this review, we discuss the available integrative models of care and evaluate their effectiveness in providing interdisciplinary interventions for supporting healthy aging, especially with a focus on the rural older adult population. Methods We undertook a literature search for models of older adult care reported between January 2000 and April 2023 that yielded 613 publications regarding proactive multidisciplinary care suited to older adults and their applicability to rural settings. Only 33 publications either focused on rural older adults or were applicable to rural older adults. Results The results highlighted the effectiveness of proactive multidisciplinary care services in improving overall well-being and quality of life for older individuals. Coordinated home care provided by a community geriatric unit demonstrated the potential to prevent avoidable hospital admissions and improve outcomes for frail older adults. Furthermore, various interprofessional education approaches showcased the value of collaborative efforts and holistic care in addressing the complex needs of geriatric patients. Conclusions This review highlights the powerful impact of integrated care models on the physical and mental health of the aging population, especially by improving the activities of daily living in frail older adults. The success of person-centered approaches and technology in multidisciplinary collaborations was evident. Further research is needed to evaluate patient-centered interventions and the long-term sustainability of integrated care models. Moreover, this review emphasizes knowledge gaps regarding healthcare access and outcomes for rural older adults, emphasizing the need for targeted interventions and policies to promote equitable access to quality healthcare. The findings provide guidance for future research and policy development to improve healthcare services and enhance the overall quality of life for older adults. Healthy aging aging in place interdisciplinary team integrated model of care independent living intersectoral collaboration interprofessional Background Recent trends in the global demographic landscape show a substantial shift towards an aging population, which increases the need to provide specialized quality care for older adults living with frailty and multiple chronic conditions ( 1 ). Frailty in the elderly leads to greater vulnerability and reduced resilience to adverse health outcomes, with one study finding that 15% of older adults living independently or in assisted living facilities are frail and an additional 45% are prefrail ( 2 ). Older adult frailty thus poses significant challenges for healthcare systems worldwide. As life expectancy increases globally, and birth rates lag, the proportion of older adults within societies is expected to rise. By 2050, it is projected that older adults over the age of 60 will constitute about 22% of the global population. Thus, it will almost double from 2015 to 2050 ( 3 ). This demographic shift not only necessitates complex healthcare solutions tailored to the older adult but also brings to the fore associated social and economic issues. In response to these challenges, the concept of healthy aging has emerged as a vital approach to addressing the multifaceted health and wellbeing needs of the aging population. Healthy aging is centered on optimizing the physical, mental, and social well-being of older adults to promote a fulfilling life and ability to live independently longer ( 3 ). To effectively address the unique healthcare needs of older adults and incorporate a preventive approach to healthy aging, there is a growing recognition of the importance of multidisciplinary and integrated care models ( 4 ). These models advocate for a patient-centered approach, combining comprehensive intervention and prevention strategies ( 3 ). Models of care are also crucial for identifying and managing frailty in older people ( 1 ). A good model of care should feature several key elements such as improved targeting of high-risk comorbidities and promotion of restorative care. It should also encourage self-management skills while coordinating care with tailored interventions and exploring new methods for effective geriatric assessment ( 5 ). The models should also enhance knowledge on frailty, support the adoption of successful health and well-being, and shift towards person-centered outcomes ( 1 ). Thus, the primary goal of an effective model of care is to extend the independence, and stabilize or reduce frailty of, older adults by addressing their physical, mental, social, and community support needs requiring multidisciplinary teams involved in older adults’ healthcare. The multidisciplinary care teams in these models must strive to address the complex challenges faced by older adults, which often extend beyond single medical conditions and require the involvement of various healthcare professionals. Integrated models of care must aim to strengthen coordination and collaboration among healthcare providers, families, and communities to deliver holistic and comprehensive care. Furthermore, implementation of these models should involve a cohesive process that encompasses awareness of the need for change, the desire among individuals to support and engage in the change, knowledge of roles and responsibilities along with appropriate training, ability to apply this knowledge in real-world settings, and reinforcement to sustain and emphasize the value of the changes made ( 5 ). In reviewing recent literature, a growing interest in employing multidisciplinary teams for the care of older adults to promote healthy aging and improve the quality of life is evident. Several care models are available that address complex healthcare needs of older adults by managing chronic conditions, enhancing physical and mental abilities, and supporting independent living. They emphasize the importance of individualized care that maintains the autonomy and dignity of each older individual. By compiling a comprehensive investigation into primary research articles on integrated care models, we aim to offer a complete overview of the current state of knowledge surrounding these models and healthy aging. The summarized evidence from this review will serve as a guiding tool for healthcare practitioners, policymakers, and researchers, highlighting potential benefits, barriers, and opportunities. Furthermore, by identifying gaps in current research and areas needing further investigation, this review contributes to future development of evidence-based interventions that promote healthy aging and enhance the quality of life for older individuals. Thus, we aim to compile an understanding of the benefits, challenges, and variations in the execution of existing multidisciplinary care models. We seek to highlight the most effective implementations and identify gaps in current practices. Methods The aim of this study was to evaluate integrative models of care and utilization of interdisciplinary interventions that support healthy aging amongst the older adult population. We focused on (1) identifying integrative models that could be implemented at the community level to improve health outcomes for older adults and (2) assess limitations and gaps in current practices. Through this review, we sought to gain insight into effective integrative interventions involved in promoting healthy aging for the geriatric population. To accomplish this goal, we conducted a comprehensive search of three electronic databases (PubMed, CINAHL, and Scopus Search). The scoping review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-analysis protocols (PRISMA-P) after being revised by the research team. The review focused on papers that discussed the implementation or evaluation of integrated models of care or interdisciplinary interventions to support healthy aging in the older adult population and improve health outcomes. We evaluated peer-reviewed journal papers meeting specific criteria (Table 1) including, but not limited to, being primary research articles published in English between January 2000 and April 2023 with a focus on intervention implementation. We explored studies that employed quantitative, qualitative, or mixed methods approaches to comprehensively evaluate the multifaceted topic of healthy aging using integrated strategies. The keyword search process involved collaboration with a medical librarian to ensure the comprehensiveness and accuracy of our search terms. The search terms and key words used for initial search were: "Aging in place" "ageing in place" "active aging" "active ageing" "healthy aging" "healthy ageing" "well aging" "well ageing" ("independent living" AND ("older adult*" OR "elderly" OR "senior*" OR "old age")) "Comprehensive geriatric assessment*" (("health*" OR "care" OR "patient*") AND ("team*" OR "collaboration*" OR "communication*") AND ("multidisciplinary" OR "interdisciplinary" OR "multiprofessional" OR "multi-professional" OR "interprofessional" OR "integrative")). This returned 1500 articles with the above specified search criteria. The 1500 articles were entered into Rayyan, the web-tool designed to help with systematic and scoping reviews. We found and removed 887 duplicated articles. Following this, two authors (PW and YG) screened the remaining 613 publications and decisions to ‘include’ or ‘exclude’ were made on the eligibility criterion detailed below and in Table 1. After the initial independent review, conflicts about study eligibility were resolved through discussions focused on the established criteria. If disagreements persisted, the criteria were revisited and amended for clarity. Final articles included or excluded were decided by a unanimous decision between the two screenings authors. Table 1. Eligibility criteria. Studies we reviewed had various definitions of the older adult population, but a consistent theme was people aged 65 or older. This specific demographic of interest allowed these studies to evaluate the effectiveness of various integrative models of care and interdisciplinary interventions in promoting healthy aging. This age group has an increased prevalence of specific health concerns and functional impairments allowing for the evaluation of how effective various interventions were at addressing their health outcomes. Out of the 613 articles initially identified, 33 were finally included in the scoping review based on the inclusion and exclusion criterion (Table 2). We performed a detailed analysis of these articles involving a summary of the main topics or themes, methods, results, and major conclusions. The data extracted focused on the various integrated model focused on the following parameters: (a) physical, mental, and social healthcare measures, (b) provision of community support, (c) utilization of an interprofessional care team, and (d) evaluation and reporting of outcomes. We utilized critical appraisal methods to assess the reliability and validity of the research findings for both qualitative and quantitative studies. Regarding qualitative research, attention was given to the research design, their inclusion and exclusion criteria, data collection methodology, and analytical techniques used with special attention paid to rigor and credibility. For quantitative studies, attention was paid to robustness of their study design, sample size included, statistical methods utilized, and sources of bias were examined. Thus, we explored evidence for research questions based on the evidence collected allowing us to shed light on the benefits and challenges of using integrated approaches with the goal of supporting the older adult population with healthy aging. Table 2. PRISMA. Results After reviewing our 33 studies included, we systematically cataloged the included articles, delineating the country of origin, study type, and participant demographics (Table 3). This comprehensive overview underscores the global span and methodological diversity of the studies, offering a critical context for understanding the breadth and depth of the research analyzed in our review. Table 3. Included Articles, by Country. Table 4 presents a detailed overview of various models of care for the elderly identified in the included studies. It lists each model alongside its corresponding authors and year of publication. The table highlights a diverse range of approaches, from integrated care services and community-based programs to specialized multidisciplinary teams and patient-centered home health care models. Table 4. Models Utilized. Table 5 highlights how different models of care for the elderly addressed physical health, as specified by the authors, though detailed explanations were not always provided. For example, the IMPACT Clinic addressed physical health within an interprofessional framework, while the Community Geriatrics Unit used the Resident Assessment Instrument-Home Care. Several models, such as the Geriatric Mobile Team (GerMot) and the Person-centered, integrated care program Care Chain Frail Elderly (CCFE), utilized comprehensive assessments like the Montreal Cognitive Assessment (MoCA) and Comprehensive Geriatric Assessment (CGA). Other approaches included interventions like the CAPABLE program, which involved occupational therapists and nurses, and the +AGIL Barcelona program, which integrated CGA with exercise, nutrition, and sleep-hygiene counseling. This table illustrates the varied methods through which physical health was incorporated into elderly care models, emphasizing the role of multidisciplinary teams and targeted assessments. Table 5. Physical Health as a component of a model. Table 6 presents how various elderly care models addressed mental health, as indicated by the authors, though specific details were not always provided. For instance, the Integrated Care Service addressed mental health using the IPOS, while the Community Geriatrics Unit and the Specialist health and social care multidisciplinary team both utilized the Geriatric Depression Scale. Some models, such as the CAPABLE program, employed tools like the PHQ-9 and Enjoyment of Life and General Activity (PEG) inventory to assess mental health. The VA-GRACE program included psychosocial assessments, and the +AGIL Barcelona program screened for cognitive impairment, depression, and loneliness. However, not all models directly addressed mental health, such as the IMPACT Clinic and the Gerontology nurse specialist-facilitated multidisciplinary team. This table highlights the diverse approaches to incorporating mental health assessments in elderly care, with a particular emphasis on using established scales and comprehensive geriatric assessments. Table 6. Mental Health as a component of a model. Table 7 outlines how various models of care for the elderly addressed the connection to community resources. Some models, like the Community Geriatrics Unit and the Geriatric Mobile Team (GerMot), directly connected participants to community resources, with GerMot also functioning as an outreach program itself. Programs such as the Multidisciplinary Team (MDT) and CAPABLE (Community Aging in Place, Advancing Better Living for Elders) not only connected participants to community resources but also provided personalized care plans or direct services, like a handyman in the case of CAPABLE. Other models, such as the Luton Framework for Frailty (LFF), connected participants to specific community resources, including a free 12-week physical activity program. However, some models, including the Integrated Care Service and the Satir Model with Motivational Interviewing techniques, did not directly provide connections to community resources. This table emphasizes the varying degrees to which elderly care models integrate community resource connections into their care strategies. Table 7. Community support as a component of a model. Table 8 summarizes the methods used to evaluate outcomes across various elderly care models. Some models, like the Integrated Care Service, used specific tools such as the IPOS to measure Quality of Life, while others, like the Community Geriatrics Unit, focused on hospitalization rates and emergency visits. CAPABLE assessed ADL performance pre- and post-intervention, and the VA-GRACE model tracked readmissions and mortality. Several models, like the Satir Model, used interviews and questionnaires, while others, such as the Specialist Health and Social Care Multidisciplinary Team, applied established evaluation frameworks. In contrast, some models did not provide detailed evaluation methods, highlighting a mix of approaches to assessing outcomes in elderly care. Table 8. Method of Evaluation of Outcomes as a component of a model. Emerged themes from studies reviewed: Proactive Multidisciplinary Care Intervention: We found that community-based healthcare models that utilized an anticipatory model of care providing multidisciplinary care services had high efficacy at improving overall wellbeing and quality of life for older adults with frailty at two to four weeks and this improvement was sustained at three months (5). To measure well-being in this specific study, they used the Integrated Palliative care Outcome Scale (IPOS) as well as a Comprehensive Geriatric Assessment (CGA)-based intervention and multi-modal interventions to improve health outcomes (5). The intervention consisted of an integrated care service with a specialized team of geriatricians, general practitioners, nurse practitioners, pharmacists, occupational therapists, social workers, physiotherapists, caregiver supports, and volunteers at a purpose-built community center compared to a control group receiving routine care at their primary care provider. Future studies need to be performed to explore this service’s effectiveness on other frailty-related outcomes, such as dependency and hospitalization. Silva-Smith et al. (2011) determined the effectiveness of a proactive primary care program on acute hospitalization and aged-residential care placement for frail older people (6). Patients received primary healthcare-based, RN-level comprehensive geriatric assessment, goal setting, care planning, and regular follow-up, along with self-management education, health and social care navigation, and transitional care for hospital discharges (6). Aged-residential care placement was significantly lower over the first year compared to matched controls (6). There was no significant difference in acute hospitalizations per year. Utilization of supportive service use like allied health therapists based on assessment for social support increased while Emergency Department-based care decreased (6). Chronic Care Model : Vestjens (2018) aimed to assess the implementation of interventions guided by the Chronic Care Model (CCM) and evaluate the perceived quality of primary care among practices utilizing the Finding and Follow-up of Frail older persons (FFF) integrated care approach (7). The intervention group of primary care physicians used the Assessment of Chronic Illness Care Short version (ACIC-S) and implemented significantly more interventions compatible with the CCM (7). The study demonstrated that the FFF approach can enhance the quality of primary care for frail older individuals according to healthcare professionals, highlighting its potential as a proactive integrated care model to address the challenges posed by an aging population and reduce pressure on healthcare systems. Satir Model and Motivational Interviewing Techniques : Juthavantana (2021) used an integrative counseling program in a Thai nursing home setting. They utilized the Satir Model and Motivational Interviewing techniques (8). The program significantly improved active aging scores, highlighting the importance of activities, group facilitators, and the group atmosphere, suggesting that psychologists and multidisciplinary teams can utilize this program to support and promote active aging in nursing home residents (8). Community Geriatrics Unit : Di (2021) compared integrated home 24/7 call service and coordinated follow-up care (provided by a community geriatric unit) in the intervention group to those receiving routine primary care (PCP) visits (9). Although the number of hospitalizations was like that in the control group, the intervention group had lower cumulative incidence for the first hospitalization after the first year of follow-up. Additionally, there were less frequent unnecessary hospitalizations, lower cumulative incidence for the first emergency room visits, and death occurred more frequently at home. This suggests that providing coordinated care at home can effectively prevent avoidable hospital admissions and improve outcomes for frail older adults, enhancing their quality of life and optimizing healthcare resource utilization (9). Ericsson (2005) provided Comprehensive Geriatric Assessments (CGA) using a geriatric mobile geriatric team (GerMoT) (10). This paper investigated the patient's perspective about being in the intervention group and found that the intervention group found the care easily assessable and provided by health professionals who knew them as a person. The CGA-based care in community-dwelling older people showed promising results and participants in GerMoT found the care was making them feel secure and safe (10). The participants thought the care was easily assessable and that providers knew them as people. Accessibility is also an issue in rural communities. ISU Senior HealthMobile partnered with the Area V Agency on Aging and assisted with community building, interagency coordination, and access to senior centers and the community process (11). The study addresses the challenges faced by older adults residing in rural communities, such as limited access to healthcare services and a lack of specialized resources (11). These factors often result in health disparities and reduced quality of care for this population. Overall, the paper highlights the potential of mobile service provision to address the unique needs of rural older adults and promote interdisciplinary practice. Informal Caregivers Involved in Shared-Decision Making : Adekpedjou (2020) presents the results of a study that explores the impact of involving caregivers in health-related housing decisions for older adults with cognitive impairment (12). They suggest that including caregivers in the decision-making process leads to improved housing outcomes and enhances the overall well-being of older adults in this population (12). Interprofessional Education : IMPACT (Interprofessional Model of Practice for Aging and Complex Treatments): Bell (2011) highlights the collaborative approach taken by the primary care team in managing the health of the geriatric patient (13). It emphasizes the importance of interdisciplinary collaboration and coordination among healthcare professionals to provide comprehensive care (13). Especially in complex geriatric patients, an interdisciplinary team with appropriate follow-up to their primary care provider is essential. They highlight the importance of understanding the limitations and abilities of the care providers to improve the patient's condition. Overall, the paper demonstrates the effectiveness of an interprofessional primary care team in addressing the complex healthcare needs of geriatric patients. It highlights the value of collaboration, shared decision-making, and a holistic approach to enhance patient outcomes and quality of care (13). Training Multi-Disciplinary Healthcare Students for Supporting Healthy Aging : Henshall (2013) implemented an interprofessional education approach via an educational event held at the University of Birmingham and University Hospital Birmingham. This was a two-day summer school for healthcare students (14). They found that key learning point for students was the need for better awareness and communication by healthcare professionals as to what services are available to older members of the community and the opportunities available for integrated working. Community Aging in Place-Advancing Better Living for Elders (CAPABLE) : The Szanton (2014) study aimed to study the impact of the Community Aging in Place, Advancing Better Living for Elders (CAPABLE) on activities of daily living (ADLs) in adults aged 65 and older living alone (15). That study found that use of the CAPABLE program is associated with a reduction in the disability of low-income older adults dually eligible for Medicare and Medicaid who are living in the community. Another study found that in all six trials of the CAPABLE program, significant enhancements were observed in activities of daily living (ADLs) and instrumental activities of daily living (IADLs), although outcomes differed across studies (16). Utilizing a lower dosage than the original protocol yielded reduced benefits. Moreover, the analysis of four studies assessing costs demonstrated that implementing CAPABLE resulted in cost savings exceeding the implementation expenses (16). During the COVID-19 pandemic, the methods were modified to include COVID-19 precautions and implementation of the CAPABLE program during the COVID-19 pandemic resulted in significant improvements in functional outcomes, instrumental activities of daily living (IADLs) independence, readiness to change, self-reported health status, and depressive symptoms among older adult participants (17). Finally, one study found that to support aging in place and accommodate the growing older adult population, healthcare policy should consider removing payment barriers to nursing care at home and prioritize cost-effective alternatives to institutional care, emphasizing the need for inter-professional strategies like CAPABLE to enhance functional ability (16, 18). Community Pharmacists : Berenbrok (2020) examines the frequency of encounters with primary care physicians compared to visits to community pharmacies among Medicare beneficiaries (19). The findings indicate that Medicare beneficiaries have more encounters with community pharmacies than with primary care physicians (13 vs 7) (19). It highlights the significance of community pharmacies as accessible healthcare resources for medication-related services and consultations. Overall, the paper sheds light on the utilization patterns of Medicare beneficiaries, highlighting the higher frequency of visits to community pharmacies compared to encounters with primary care physicians (19). It underscores the importance of leveraging community pharmacies as integral components of the healthcare system to provide comprehensive care and support to older adults. VA-GRACE : The Schubert (2022) study evaluated the VA Geriatric Resources for Assessment and Care of Elders (VA-GRACE) program's effect on mortality and readmissions, as well as patient, caregiver, and staff satisfaction (15). Widespread deployment of programs like VA-GRACE will be required to support the Veteran population to age in place. The Geriatric Resources for Assessment and Care of Elders (GRACE) program is a collaborative, multidisciplinary care model which provides home-based geriatric care management. In a randomized controlled trial, GRACE improved quality of care and reduced healthcare utilization compared to usual care (15). Model of Career and Technical Education: Skills for Health Aging Resources and Programs (SHARP) : Frank (2022) study evaluated a career and technical education program that aimed to prepare the workforce for healthy aging programs. They performed a multiyear evaluation with data collected at baseline, midpoint of the program, post-program, and follow-up between 9- and 12-months addressing outcomes at four levels: program, college, faculty, and student (20). There was a significant increase in all four of the items related to EBHP (evidence-based health promotion) and disease management (history of EBHP, documented positive outcomes of EBHP programs, delivery system, specific EBHP model programs) (20). All 13 competencies showed a significant difference between pre and post (20). SHARP addresses aging service educational deficits and supports the growth of EBHPs through workforce preparation (20). This represents the first-ever reported evaluation of a college-level training program in EBHP community-based program delivery for older adults (20). Care Chain Frail Elderly (CCFE) : The Care Chain Frail Elderly (CCFE) program is a person-centered, integrated service, and community-based care service (21). Hoedemakers (2022) study found that the CCFE is the preferred way of delivering care to frail older adults at six months according to multicriteria decision analysis (MCDA). At 12 months, MCDA results showed little difference from the perspective of patients, informal caregivers, and professionals while payers and policymakers seemed to prefer usual care. The findings of the study shed light on the efficacy of the value-based person-centered integrated care approach in improving the quality of life, health outcomes, and satisfaction levels of frail older adult individuals living at home. Luton Framework for Frailty (LFF) and Implementation of an integrated care service for older people with different frailty levels (OPDFL) : The Khan (2023) study concluded that LFF is a promising initiative and lessons learned are likely transferrable to other settings as proactive management of frailty takes on greater policy prominence in the UK and worldwide (22). LFF supports older people with healthy aging to remain in their homes as long as possible. LFF promotes healthy aging, identifying frail older adults, proactively manages their care, and reduces the need for those aged over 65 to be urgently admitted to the hospital (22). This study's conclusion highlights the in-depth qualitative analysis of an integrated care program for older people with frailty (OPDFL) and identifies factors influencing its implementation. The findings suggest that involving older people in the design of interventions is crucial for their success, and the development of multidisciplinary teams (MDTs) is beneficial for managing complex cases (22). However, further evaluation is needed to understand the variations in MDT implementation. Additionally, establishing common data systems for both primary and secondary care is recommended (22). Health Teams Advancing Patient Experience: Strengthening Quality (Health TAPESTRY) : Health Teams Advancing Patient Experience: Strengthening Quality (Health TAPESTRY) is a primary care intervention aimed at supporting older adults that involves trained volunteers, interprofessional teams, technology, and system navigation (23). Valaites’ (2020) paper examines implementation of Health TAPESTRY in relation to interprofessional teamwork including volunteers (23). This study concluded that regular communication among all team members, the development of procedures and/or protocols to support team processes, and ongoing review and feedback are critical to implementation of innovations involving primary care teams (23). Patient-Centered Integrated Model of Home Health Care Services in South Korea (PICS-K) : Mun (2020) PICS-K has six main features: integration of primary care-hospital-personal care-social services through a consortium, home health support center (HHSC) in hospitals with primary care collaboration, increased accessibility, interdisciplinary team (IDT), patient-centeredness, and education (24). The National Health Insurance Service (NHIS) established an IDT home health support center in a public hospital in August 2021 (24). They performed a case study of the first year of the initiatives. NHIS is considering a home healthcare model for implementation based on the results of these initiatives that can be applied nationwide (24). The importance is that PICS-K is an appropriate model for nationwide implementation, but the authors list numerous steps that must be taken first like regional hospitals having existing PCPs performing home visits, building of home healthcare centers in primary care clinics (24). Discussion The themes that emerged from the reviewed studies highlight various proactive and integrated care interventions aimed at improving the wellbeing and quality of life of older adults (5-7, 16, 18, 25). Community-based studies involving multidisciplinary care services demonstrated sustained improvements in overall wellbeing and quality of life for frail older individuals (5, 7, 12, 26, 27). Additionally, comprehensive geriatric assessments, goal-setting, and regular follow-up interventions have shown promising results in reducing aged-residential care placement and unnecessary hospitalizations (6, 10, 22, 23). Implementing interventions guided by the Chronic Care Model has proven effective in enhancing the quality of primary care for frail older individuals, showcasing its potential as a proactive integrated care approach (7). Moreover, the use of integrative counseling programs, such as the Satir Model and Motivational Interviewing techniques, has significantly improved active aging scores among older adult populations in nursing homes (8). Collaborative efforts by community geriatrics units and the involvement of caregivers in shared decision-making have also shown positive outcomes, including reduced avoidable hospital admissions and improved housing outcomes for older adults with cognitive impairment (9-11). Interprofessional management teams have proven valuable in managing the complex healthcare needs of geriatric patients, emphasizing the significance of collaboration and a holistic approach to enhance patient outcomes and quality of care (4, 13, 25, 28, 29). Similarly, initiatives like the Community Aging in Place-Advancing Better Living for Elders (CAPABLE) have demonstrated significant reductions in disability and functional improvements in older adults living in the community, indicating the potential for cost-effective alternatives to institutional care (16-18, 25, 30). Community pharmacists play a vital role in providing accessible healthcare resources for medication-related services and consultations for older adults (19). The VA Geriatric Resources for Assessment and Care of Elders (VA-GRACE) program and the Model of Career and Technical Education: Skills for Healthy Aging Resources and Programs (SHARP) have shown promising results in improving care management and enhancing the growth of evidence-based health promotion programs for older adults (15, 20). The Care Chain Frail Elderly (CCFE) program has proven effective in providing person-centered, integrated care services for frail older adult individuals living at home (21). Furthermore, initiatives like the Luton Framework for Frailty (LFF) and Health Teams Advancing Patient Experience: Strengthening Quality (Health TAPESTRY) demonstrate the importance of interprofessional teamwork, regular communication, and feedback in implementing innovative primary care interventions (22, 23). Our comprehensive review, as illustrated in Table 4-8, examined a range of healthcare models designed for the geriatric population, evaluating their coverage of essential older adult care aspects: physical, mental, and social health, alongside community support. A salient feature across the models was the integration of interprofessional teams, which are critical for delivering holistic geriatric care. The analysis also focused on the presence of structured outcome evaluation methods, which are crucial for verifying the effectiveness and guiding the refinement of care services. All these features appear to be crucial when answering the question: what makes a good model of care? Hence, based on the evidence from this review, we believe that a good model of care should include the following but not limited key elements: interprofessional collaboration, comprehensive geriatric assessments (CGA) with goal setting, proactive and preventive care, and community-based, accessible care. From the data in Tables 5-8, it became clear that most healthcare models encompassed many if not all key elements of integrated care delivery. One key element of this was addressing a participant’s physical health (31). It is critical that older persons maintain their physical well-being to live healthy lives and prevent age-related health issues (31). Mental health is another key element that must be addressed in a model of care (32). Addressing people’s social health is essential as social participation is linked to several benefits such as better sleep, better cognitive function, and lower levels of depression (33-36). The consistent and unanimous inclusion of various health aspects and the application of an interprofessional approach indicate a comprehensive understanding of the multifaceted nature of geriatric care within the field. Furthermore, the widespread implementation of outcome evaluation mechanisms suggests a commitment to ongoing improvement and accountability in older adult care models (5, 7, 8, 10, 15, 16). Our analysis, however, reveals significant gaps in knowledge concerning the rural older population and their access to healthcare services and health outcomes. Despite advancements in healthcare, there remains a scarcity of comprehensive studies and data specifically focused on rural older adults. Existing research tends to predominantly concentrate on urban or suburban populations, inadvertently overlooking the unique challenges faced by those residing in rural areas. Life expectancy in the U.S. is inversely related to rurality, with those in large metropolitan areas enjoying higher life expectancy (79.1 years) compared to residents of small towns (76.9 years) and rural areas (76.7 years) in 2005-2009. Over four decades, the disparity between rural and urban areas widened, with the life expectancy gap increasing from 0.4 years in 1969-1971 to 2.0 years in 2005-2009. Notably, rural poor and rural black populations now have life expectancies comparable to urban populations from forty years ago. The key causes of death driving these disparities include heart disease, unintentional injuries, COPD, lung cancer, stroke, suicide, and diabetes, highlighting the urgent need for targeted healthcare interventions in rural areas (37). Older adults in rural areas face significant disparities in health outcomes compared to their urban counterparts (38). Between 1999 and 2019, rural areas consistently had higher age-adjusted mortality rates (AAMRs) than urban areas (38). For example, while AAMRs in large metropolitan areas decreased from 861.5 per 100,000 to 664.5 per 100,000, in rural areas, they only decreased from 923.8 per 100,000 to 834.0 per 100,000 (38). This disparity grew over time, with the gap in AAMRs between rural and urban areas more than doubling during this period (38). Additionally, rural older adults tend to have poorer health outcomes, with higher rates of chronic diseases, such as heart disease and diabetes, and face more significant barriers to healthcare access, contributing to lower life expectancy and overall poorer health outcomes (39). Limited access to healthcare facilities, healthcare providers, and specialized services in rural regions has resulted in disparities in health outcomes for older individuals (40). Additionally, the intricate interplay of social determinants, such as transportation barriers, socioeconomic status, and geographic isolation, further exacerbates the healthcare disparities experienced by this population (40). Understanding these gaps is crucial for developing targeted interventions and policies that address the specific needs of rural older adults, ultimately promoting equitable access to quality healthcare and improved health outcomes for this vulnerable demographic. In conclusion, the reviewed studies emphasize the effectiveness of proactive and integrated care interventions in enhancing wellbeing, quality of life, and overall healthcare outcomes for older adults. These findings underscore the importance of collaborative efforts, interdisciplinary approaches, and person-centered care models to address the unique needs of the aging population and promote healthy aging in different healthcare settings. Implementing such interventions can optimize healthcare resource utilization and improve the quality of care for older individuals. However, further research and evaluation are needed to explore their impact on other frailty-related outcomes and to better understand the variations in implementation across urban and rural contexts. Conclusions In conclusion, the analysis of current literature underscores the significant benefits of proactive, integrated care interventions that are tailored to the geriatric population. These interventions, as evidenced by improvements in well-being, quality of life, and healthcare outcomes, validate the need for collaborative, multidisciplinary approaches centered around the patient. The research notably highlights the critical role of interprofessional teams and outcome evaluations in enhancing geriatric care. However, our review also uncovers a crucial deficiency in our understanding of the healthcare challenges faced by rural older adults, signaling a call for targeted research and tailored strategies to mitigate disparities in this demographic. As the healthcare landscape evolves, the importance of adaptable, person-centered care models grows, promising improved care quality for older adults. To foster this advancement, further studies are necessary to deepen our grasp of the effectiveness of these interventions across varied populations and settings. Abbreviations CAPABLE (Community Aging in Place—Advancing Better Living for Elders) CCM (Chronic Care Model) CCFE (Care Chain Frail Elderly) DGIP (Dutch EASYcare Study Geriatric Intervention Program) FFF (Finding and Follow-up of Frail older persons) GerMoT (Geriatric Mobile Team) Health TAPESTRY (Health Teams Advancing Patient Experience: Strengthening Quality IMPACT (Interprofessional Model of Practice for Aging and Complex Treatments) Luton Framework for Frailty (LFF) PICS-K (Patient-Centered Integrated Model of Home Health Care Services in South Korea) SDM (Shared-Decision Making) SHARP (Skills for Health Aging Resources and Programs) VA-GRACE (Veteran’s Affairs Geriatric Resources for Assessment and Care of Elders) Declarations Ethics approval and consent to participate All included sources were from trustworthy, peer-reviewed, and database indexed publications. Articles included via hand searching were not indexed in the four databases searched explicitly but were available elsewhere. IRB approval was not sought for this project as all included studies had already obtained IRB approval. Although using studies published in peer-reviewed journals helps ensure quality, it also introduces the potential for publication and reporting bias, limiting the generalizability of the results. This may limit representation from studies with null or negative findings since studies with positive findings or higher satisfaction rates may be more likely to be published or submitted for publishing, potentially skewing the results. Consent for publication Not applicable. Availability of data and materials Data sharing is not applicable to this article as no datasets were generated or analyzed during the current study. Competing interests The authors declare that they have no competing interests. Funding No funding was attained to support this research. Clinical trial number Not applicable. Authors' contributions PW, YG, and JP engaged in the conception and design of the work. PW and YG did the acquisition, analysis, and interpretation of data. PW and YG initially drafted the work, and AF substantively revised it and prepared the manuscript for submission. JP provided mentorship and oversight and will serve as corresponding author. All authors have approved the submitted version of this manuscript and agreed both to be personally accountable for their own contributions and to ensure that questions related to the accuracy or integrity of any part of the work, even ones in which they are not personally involved, are appropriately investigated, resolved, and the resolution is documented in the literature. Acknowledgements Not applicable. References Clegg A, Young J, Iliffe S, Rikkert MO, Rockwood K. Frailty in elderly people. Lancet. 2013;381(9868):752-62. Bandeen-Roche K, Seplaki CL, Huang J, Buta B, Kalyani RR, Varadhan R, et al. Frailty in Older Adults: A Nationally Representative Profile in the United States. J Gerontol A Biol Sci Med Sci. 2015;70(11):1427-34. Officer A, Thiyagarajan JA, Schneiders ML, Nash P, de la Fuente-Núñez V. Ageism, Healthy Life Expectancy and Population Ageing: How Are They Related? Int J Environ Res Public Health. 2020;17(9). Clarke JL, Bourn S, Skoufalos A, Beck EH, Castillo DJ. An Innovative Approach to Health Care Delivery for Patients with Chronic Conditions. Popul Health Manag. 2017;20(1):23-30. Murtagh FEM, Okoeki M, Ukoha-kalu BO, Khamis A, Clark J, Boland JW, et al. A non-randomised controlled study to assess the effectiveness of a new proactive multidisciplinary care intervention for older people living with frailty. BMC Geriatrics. 2023;23(1):6. Silva-Smith AL, Feliciano L, Kluge MA, Yochim BP, Anderson LN, Hiroto KE, et al. The Palisades: an interdisciplinary wellness model in senior housing. Gerontologist. 2011;51(3):406-14. Vestjens L, Cramm JM, Nieboer AP. An integrated primary care approach for frail community-dwelling older persons: a step forward in improving the quality of care. BMC Health Services Research. 2018;18(1):28. Juthavantana J, Sakunpong N, Prasertsin U, Charupheng M, Lau SH. An integrative counselling program to promote active ageing for older people in Thai nursing homes: an intervention mixed methods design. BMC Psychol. 2021;9(1):14. Di Pollina L, Guessous I, Petoud V, Combescure C, Buchs B, Schaller P, et al. Integrated care at home reduces unnecessary hospitalizations of community-dwelling frail older adults: a prospective controlled trial. BMC Geriatr. 2017;17(1):53. Ericsson I, Ekdahl AW, Hellström I. "To be seen" - older adults and their relatives' care experiences given by a geriatric mobile team (GerMoT). BMC Geriatr. 2021;21(1):636. Hayward KS. Facilitating interdisciplinary practice through mobile service provision to the rural older adult. Geriatric Nursing. 2005;26(1):29-33. Adekpedjou R, Stacey D, Brière N, Freitas A, Garvelink MM, Dogba MJ, et al. Engaging Caregivers in Health-Related Housing Decisions for Older Adults With Cognitive Impairment: A Cluster Randomized Trial. Gerontologist. 2020;60(5):947-57. Bell SH, Tracy CS, Upshur RE. The assessment and treatment of a complex geriatric patient by an interprofessional primary care team. BMJ Case Rep. 2011;2011. Henshall C, Bartlett D, Lord J, Gale N. Supporting Healthy Ageing: training multi-disciplinary healthcare students. European Journal of Integrative Medicine. 2013;6. Schubert CC, Perkins AJ, Myers LJ, Damush TM, Penney LS, Zhang Y, et al. Effectiveness of the VA-Geriatric Resources for Assessment and Care of Elders (VA-GRACE) program: An observational cohort study. J Am Geriatr Soc. 2022;70(12):3598-609. Szanton SL, Wolff JW, Leff B, Thorpe RJ, Tanner EK, Boyd C, et al. CAPABLE trial: a randomized controlled trial of nurse, occupational therapist and handyman to reduce disability among older adults: rationale and design. Contemp Clin Trials. 2014;38(1):102-12. Pho AT, Tanner EK, Roth J, Greeley ME, Dorsey CD, Szanton SL. Nursing strategies for promoting and maintaining function among community-living older adults: the CAPABLE intervention. Geriatr Nurs. 2012;33(6):439-45. Szanton SL, Leff B, Li Q, Breysse J, Spoelstra S, Kell J, et al. CAPABLE program improves disability in multiple randomized trials. J Am Geriatr Soc. 2021;69(12):3631-40. Berenbrok LA, Gabriel N, Coley KC, Hernandez I. Evaluation of Frequency of Encounters With Primary Care Physicians vs Visits to Community Pharmacies Among Medicare Beneficiaries. JAMA Netw Open. 2020;3(7):e209132. Frank J, Altpeter M, Damron-Rodriguez J, Driggers J, Lachenmayr S, Manning C, et al. Preparing the Workforce for Healthy Aging Programs: The Skills for Healthy Aging Resources and Programs (SHARP) Model. Health education & behavior : the official publication of the Society for Public Health Education. 2014;41:19S-26S. Hoedemakers M, Karimi M, Leijten F, Goossens L, Islam K, Tsiachristas A, et al. Value-based person-centred integrated care for frail elderly living at home: a quasi-experimental evaluation using multicriteria decision analysis. BMJ Open. 2022;12(4):e054672. Khan N, Randhawa G, Hewson D. Integrated Care for Older People with Different Frailty Levels: A Qualitative Study of Local Implementation of a National Policy in Luton, England. Int J Integr Care. 2023;23(1):15. Valaitis R, Cleghorn L, Dolovich L, Agarwal G, Gaber J, Mangin D, et al. Examining Interprofessional teams structures and processes in the implementation of a primary care intervention (Health TAPESTRY) for older adults using normalization process theory. BMC Family Practice. 2020;21(1):63. Mun H, Cho K, Lee S, Choi Y, Oh SJ, Kim YS, et al. Patient-Centered Integrated Model of Home Health Care Services in South Korea (PICS-K). Int J Integr Care. 2023;23(2):6. Cacchione PZ. Innovative care models across settings: Providing nursing care to older adults. Geriatric Nursing. 2020;41(1):16-20. Drennan V, Iliffe S, Haworth D, Tai SS, Lenihan P, Deave T. The feasibility and acceptability of a specialist health and social care team for the promotion of health and independence in ‘at risk’ older adults. Health & Social Care in the Community. 2005;13(2):136-44. Bloomfield K, Wu Z, Broad JB, Tatton A, Calvert C, Hikaka J, et al. Learning from a multidisciplinary randomized controlled intervention in retirement village residents. J Am Geriatr Soc. 2022;70(3):743-53. Gustafsson LK, Östlund G, Zander V, Elfström ML, Anbäcken EM. 'Best fit' caring skills of an interprofessional team in short-term goal-directed reablement: older adults' perceptions. Scand J Caring Sci. 2019;33(2):498-506. Oeseburg B, Hilberts R, Luten TA, van Etten AV, Slaets JP, Roodbol PF. Interprofessional education in primary care for the elderly: a pilot study. BMC Med Educ. 2013;13:161. Washington SE, Edwards E, Stiles DL, West Bruce S. Implementation of the CAPABLE Program With Older Adults During the COVID-19 Pandemic. OTJR (Thorofare N J). 2023;43(4):683-90. Hung ST, Cheng YC, Wu CC, Su CH. Examining Physical Wellness as the Fundamental Element for Achieving Holistic Well-Being in Older Persons: Review of Literature and Practical Application in Daily Life. J Multidiscip Healthc. 2023;16:1889-904. Reynolds CF, 3rd, Jeste DV, Sachdev PS, Blazer DG. Mental health care for older adults: recent advances and new directions in clinical practice and research. World Psychiatry. 2022;21(3):336-63. Chen JH, Lauderdale DS, Waite LJ. Social participation and older adults' sleep. Soc Sci Med. 2016;149:164-73. Bowling A, Pikhartova J, Dodgeon B. Is mid-life social participation associated with cognitive function at age 50? Results from the British National Child Development Study (NCDS). BMC Psychol. 2016;4(1):58. Kotwal AA, Kim J, Waite L, Dale W. Social Function and Cognitive Status: Results from a US Nationally Representative Survey of Older Adults. J Gen Intern Med. 2016;31(8):854-62. Croezen S, Avendano M, Burdorf A, van Lenthe FJ. Social participation and depression in old age: a fixed-effects analysis in 10 European countries. Am J Epidemiol. 2015;182(2):168-76. Singh GK, Siahpush M. Widening rural-urban disparities in life expectancy, U.S., 1969-2009. Am J Prev Med. 2014;46(2):e19-29. Cross SH, Califf RM, Warraich HJ. Rural-Urban Disparity in Mortality in the US From 1999 to 2019. JAMA. 2021;325(22):2312-4. Cohen SA, Greaney ML. Aging in Rural Communities. Curr Epidemiol Rep. 2023;10(1):1-16. van Gaans D, Dent E. Issues of accessibility to health services by older Australians: a review. Public Health Rev. 2018;39:20. Economic UNDoI, Economic UNDf, Analysis P. World population prospects: United Nations, Department of International, Economic and Social Affairs; 2001. Ekelund C, Eklund K. Longitudinal effects on self-determination in the RCT "Continuum of care for frail elderly people". Quality in Ageing and Older Adults. 2015;16:165-76. Featherstone A. Developing a holistic, multidisciplinary community service for frail older people. Nurs Older People. 2018;30(7):34-40. Inzitari M, Pérez LM, Enfedaque MB, Soto L, Díaz F, Gual N, et al. Integrated primary and geriatric care for frail older adults in the community: Implementation of a complex intervention into real life. Eur J Intern Med. 2018;56:57-63. Robinson TE, Boyd ML, North D, Wignall J, Dawe M, McQueen J, et al. Proactive primary care model for frail older people in New Zealand delays aged-residential care: A quasi-experiment. J Am Geriatr Soc. 2021;69(6):1617-26. Romera-Liebana L, Orfila F, Segura JM, Real J, Fabra ML, Möller M, et al. Effects of a Primary Care-Based Multifactorial Intervention on Physical and Cognitive Function in Frail, Elderly Individuals: A Randomized Controlled Trial. J Gerontol A Biol Sci Med Sci. 2018;73(12):1688-74. Suijker JJ, van Rijn M, Buurman BM, Ter Riet G, Moll van Charante EP, de Rooij SE. Effects of Nurse-Led Multifactorial Care to Prevent Disability in Community-Living Older People: Cluster Randomized Trial. PLoS One. 2016;11(7):e0158714. Clark JM, Sanders S, Carter M, Honeyman D, Cleo G, Auld Y, et al. Improving the translation of search strategies using the Polyglot Search Translator: a randomized controlled trial. J Med Libr Assoc. 2020;108(2):195-207. Tables Tables 1 to 8 are available in the Supplementary Files section Additional Declarations No competing interests reported. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6221967","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Systematic Review","associatedPublications":[],"authors":[{"id":445830279,"identity":"72689c74-5aaf-4f7e-abbd-f23d6d454a16","order_by":0,"name":"Payton Wolbert","email":"","orcid":"","institution":"Central Michigan University","correspondingAuthor":false,"prefix":"","firstName":"Payton","middleName":"","lastName":"Wolbert","suffix":""},{"id":445830280,"identity":"a504af8d-cf77-4826-89f0-9f8e9237f9f1","order_by":1,"name":"Yousif Gariaqoza","email":"","orcid":"","institution":"Central Michigan University","correspondingAuthor":false,"prefix":"","firstName":"Yousif","middleName":"","lastName":"Gariaqoza","suffix":""},{"id":445830284,"identity":"08f8518d-1195-4ddb-88ab-de6355cc15ab","order_by":2,"name":"Alexander Forrest","email":"","orcid":"","institution":"Central Michigan University","correspondingAuthor":false,"prefix":"","firstName":"Alexander","middleName":"","lastName":"Forrest","suffix":""},{"id":445830286,"identity":"eee37c76-954a-417f-a81f-653c3d48cab3","order_by":3,"name":"Jyotsna Pandey","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAwklEQVRIiWNgGAWjYJACCQYDNjkGBsYGZgYQSZyWAjZjUrV8YEgEqSROizn72YM3PhjwpfdPO9z4uYDBRnbDAQJaLHvyki1nGLDlzrid2Cw9gyHNmKAWgwM5ZtI8QC0bpBPbmHkYDicS1nL+jZn0HwO2dAOIlv9EaLkBtAUYyAlQLQcIa7Gc8cbYsseAzRDsFx6DZOOZhLSY8+cY3vjx55g8/+z0h595Kuxk+wg6DEIdQ+USo6WGCKWjYBSMglEwYgEAohE/hdkw1SkAAAAASUVORK5CYII=","orcid":"","institution":"Central Michigan University","correspondingAuthor":true,"prefix":"","firstName":"Jyotsna","middleName":"","lastName":"Pandey","suffix":""}],"badges":[],"createdAt":"2025-03-13 17:08:17","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6221967/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6221967/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":96251283,"identity":"29dfcfa6-4def-45f6-9724-5281a00e602e","added_by":"auto","created_at":"2025-11-19 07:39:36","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":951887,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6221967/v1/9ab3340e-0176-4e48-83f4-b736dca54408.pdf"},{"id":81263361,"identity":"899491e9-bfb7-4825-b2b6-aaf2838335fe","added_by":"auto","created_at":"2025-04-24 06:54:28","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":109045,"visible":true,"origin":"","legend":"","description":"","filename":"Tables.docx","url":"https://assets-eu.researchsquare.com/files/rs-6221967/v1/b233d89d291f7170f417431c.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Integrative Models of Care for Healthy Aging in the Elderly: A Narrative Review","fulltext":[{"header":"Background","content":"\u003cp\u003eRecent trends in the global demographic landscape show a substantial shift towards an aging population, which increases the need to provide specialized quality care for older adults living with frailty and multiple chronic conditions (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). Frailty in the elderly leads to greater vulnerability and reduced resilience to adverse health outcomes, with one study finding that 15% of older adults living independently or in assisted living facilities are frail and an additional 45% are prefrail (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). Older adult frailty thus poses significant challenges for healthcare systems worldwide. As life expectancy increases globally, and birth rates lag, the proportion of older adults within societies is expected to rise. By 2050, it is projected that older adults over the age of 60 will constitute about 22% of the global population. Thus, it will almost double from 2015 to 2050 (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). This demographic shift not only necessitates complex healthcare solutions tailored to the older adult but also brings to the fore associated social and economic issues. In response to these challenges, the concept of healthy aging has emerged as a vital approach to addressing the multifaceted health and wellbeing needs of the aging population. Healthy aging is centered on optimizing the physical, mental, and social well-being of older adults to promote a fulfilling life and ability to live independently longer (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eTo effectively address the unique healthcare needs of older adults and incorporate a preventive approach to healthy aging, there is a growing recognition of the importance of multidisciplinary and integrated care models (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e). These models advocate for a patient-centered approach, combining comprehensive intervention and prevention strategies (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). Models of care are also crucial for identifying and managing frailty in older people (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). A good model of care should feature several key elements such as improved targeting of high-risk comorbidities and promotion of restorative care. It should also encourage self-management skills while coordinating care with tailored interventions and exploring new methods for effective geriatric assessment (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e). The models should also enhance knowledge on frailty, support the adoption of successful health and well-being, and shift towards person-centered outcomes (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThus, the primary goal of an effective model of care is to extend the independence, and stabilize or reduce frailty of, older adults by addressing their physical, mental, social, and community support needs requiring multidisciplinary teams involved in older adults\u0026rsquo; healthcare. The multidisciplinary care teams in these models must strive to address the complex challenges faced by older adults, which often extend beyond single medical conditions and require the involvement of various healthcare professionals. Integrated models of care must aim to strengthen coordination and collaboration among healthcare providers, families, and communities to deliver holistic and comprehensive care. Furthermore, implementation of these models should involve a cohesive process that encompasses awareness of the need for change, the desire among individuals to support and engage in the change, knowledge of roles and responsibilities along with appropriate training, ability to apply this knowledge in real-world settings, and reinforcement to sustain and emphasize the value of the changes made (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eIn reviewing recent literature, a growing interest in employing multidisciplinary teams for the care of older adults to promote healthy aging and improve the quality of life is evident. Several care models are available that address complex healthcare needs of older adults by managing chronic conditions, enhancing physical and mental abilities, and supporting independent living. They emphasize the importance of individualized care that maintains the autonomy and dignity of each older individual.\u003c/p\u003e \u003cp\u003eBy compiling a comprehensive investigation into primary research articles on integrated care models, we aim to offer a complete overview of the current state of knowledge surrounding these models and healthy aging. The summarized evidence from this review will serve as a guiding tool for healthcare practitioners, policymakers, and researchers, highlighting potential benefits, barriers, and opportunities. Furthermore, by identifying gaps in current research and areas needing further investigation, this review contributes to future development of evidence-based interventions that promote healthy aging and enhance the quality of life for older individuals. Thus, we aim to compile an understanding of the benefits, challenges, and variations in the execution of existing multidisciplinary care models. We seek to highlight the most effective implementations and identify gaps in current practices.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eThe aim of this study was to evaluate integrative models of care and utilization of interdisciplinary interventions that support healthy aging amongst the older adult population. We focused on (1) identifying integrative models that could be implemented at the community level to improve health outcomes for older adults and (2) assess limitations and gaps in current practices. Through this review, we sought to gain insight into effective integrative interventions involved in promoting healthy aging for the geriatric population. To accomplish this goal, we conducted a comprehensive search of three electronic databases (PubMed, CINAHL, and Scopus Search). The scoping review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-analysis protocols (PRISMA-P) after being revised by the research team. The review focused on papers that discussed the implementation or evaluation of integrated models of care or interdisciplinary interventions to support healthy aging in the older adult population and improve health outcomes. We evaluated peer-reviewed journal papers meeting specific criteria (Table 1) including, but not limited to, being primary research articles published in English between January 2000 and April 2023 with a focus on intervention implementation. We explored studies that employed quantitative, qualitative, or mixed methods approaches to comprehensively evaluate the multifaceted topic of healthy aging using integrated strategies. The keyword search process involved collaboration with a medical librarian to ensure the comprehensiveness and accuracy of our search terms. The search terms and key words used for initial search were: \u0026quot;Aging in place\u0026quot; \u0026quot;ageing in place\u0026quot; \u0026quot;active aging\u0026quot; \u0026quot;active ageing\u0026quot; \u0026quot;healthy aging\u0026quot; \u0026quot;healthy ageing\u0026quot; \u0026quot;well aging\u0026quot; \u0026quot;well ageing\u0026quot; (\u0026quot;independent living\u0026quot; AND (\u0026quot;older adult*\u0026quot; OR \u0026quot;elderly\u0026quot; OR \u0026quot;senior*\u0026quot; OR \u0026quot;old age\u0026quot;)) \u0026quot;Comprehensive geriatric assessment*\u0026quot; ((\u0026quot;health*\u0026quot; OR \u0026quot;care\u0026quot; OR \u0026quot;patient*\u0026quot;) AND (\u0026quot;team*\u0026quot; OR \u0026quot;collaboration*\u0026quot; OR \u0026quot;communication*\u0026quot;) AND (\u0026quot;multidisciplinary\u0026quot; OR \u0026quot;interdisciplinary\u0026quot; OR \u0026quot;multiprofessional\u0026quot; OR \u0026quot;multi-professional\u0026quot; OR \u0026quot;interprofessional\u0026quot; OR \u0026quot;integrative\u0026quot;)).\u003c/p\u003e\n\u003cp\u003eThis returned 1500 articles with the above specified search criteria. The 1500 articles were entered into Rayyan, the web-tool designed to help with systematic and scoping reviews. We found and removed 887 duplicated articles. Following this, two authors (PW and YG) screened the remaining 613 publications and decisions to \u0026lsquo;include\u0026rsquo; or \u0026lsquo;exclude\u0026rsquo; were made on the eligibility criterion detailed below and in Table 1. After the initial independent review, conflicts about study eligibility were resolved through discussions focused on the established criteria. If disagreements persisted, the criteria were revisited and amended for clarity. Final articles included or excluded were decided by a unanimous decision between the two screenings authors.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 1. Eligibility criteria.\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eStudies we reviewed had various definitions of the older adult population, but a consistent theme was people aged 65 or older. This specific demographic of interest allowed these studies to evaluate the effectiveness of various integrative models of care and interdisciplinary interventions in promoting healthy aging. This age group has an increased prevalence of specific health concerns and functional impairments allowing for the evaluation of how effective various interventions were at addressing their health outcomes.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eOut of the 613 articles initially identified, 33 were finally included in the scoping review based on the inclusion and exclusion criterion (Table 2). We performed a detailed analysis of these articles involving a summary of the main topics or themes, methods, results, and major conclusions. The data extracted focused on the various integrated model focused on the following parameters: (a) physical, mental, and social healthcare measures, (b) provision of community support, (c) utilization of an interprofessional care team, and (d) evaluation and reporting of outcomes.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eWe utilized critical appraisal methods to assess the reliability and validity of the research findings for both qualitative and quantitative studies. Regarding qualitative research, attention was given to the research design, their inclusion and exclusion criteria, data collection methodology, and analytical techniques used with special attention paid to rigor and credibility. For quantitative studies, attention was paid to robustness of their study design, sample size included, statistical methods utilized, and sources of bias were examined. Thus, we explored evidence for research questions based on the evidence collected allowing us to shed light on the benefits and challenges of using integrated approaches with the goal of supporting the older adult population with healthy aging.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 2. PRISMA.\u003c/strong\u003e\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eAfter reviewing our 33 studies included, we systematically cataloged the included articles, delineating the country of origin, study type, and participant demographics (Table 3). This comprehensive overview underscores the global span and methodological diversity of the studies, offering a critical context for understanding the breadth and depth of the research analyzed in our review.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 3. Included Articles, by Country.\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eTable 4 presents a detailed overview of various models of care for the elderly identified in the included studies. It lists each model alongside its corresponding authors and year of publication. The table highlights a diverse range of approaches, from integrated care services and community-based programs to specialized multidisciplinary teams and patient-centered home health care models.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 4. Models Utilized.\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eTable 5 highlights how different models of care for the elderly addressed physical health, as specified by the authors, though detailed explanations were not always provided. For example, the IMPACT Clinic addressed physical health within an interprofessional framework, while the Community Geriatrics Unit used the Resident Assessment Instrument-Home Care. Several models, such as the Geriatric Mobile Team (GerMot) and the Person-centered, integrated care program Care Chain Frail Elderly (CCFE), utilized comprehensive assessments like the Montreal Cognitive Assessment (MoCA) and Comprehensive Geriatric Assessment (CGA). Other approaches included interventions like the CAPABLE program, which involved occupational therapists and nurses, and the +AGIL Barcelona program, which integrated CGA with exercise, nutrition, and sleep-hygiene counseling. This table illustrates the varied methods through which physical health was incorporated into elderly care models, emphasizing the role of multidisciplinary teams and targeted assessments.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 5. Physical Health as a component of a model.\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eTable 6 presents how various elderly care models addressed mental health, as indicated by the authors, though specific details were not always provided. For instance, the Integrated Care Service addressed mental health using the IPOS, while the Community Geriatrics Unit and the Specialist health and social care multidisciplinary team both utilized the Geriatric Depression Scale. Some models, such as the CAPABLE program, employed tools like the PHQ-9 and Enjoyment of Life and General Activity (PEG) inventory to assess mental health. The VA-GRACE program included psychosocial assessments, and the +AGIL Barcelona program screened for cognitive impairment, depression, and loneliness. However, not all models directly addressed mental health, such as the IMPACT Clinic and the Gerontology nurse specialist-facilitated multidisciplinary team. This table highlights the diverse approaches to incorporating mental health assessments in elderly care, with a particular emphasis on using established scales and comprehensive geriatric assessments.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 6. Mental Health as a component of a model.\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eTable 7 outlines how various models of care for the elderly addressed the connection to community resources. Some models, like the Community Geriatrics Unit and the Geriatric Mobile Team (GerMot), directly connected participants to community resources, with GerMot also functioning as an outreach program itself. Programs such as the Multidisciplinary Team (MDT) and CAPABLE (Community Aging in Place, Advancing Better Living for Elders) not only connected participants to community resources but also provided personalized care plans or direct services, like a handyman in the case of CAPABLE. Other models, such as the Luton Framework for Frailty (LFF), connected participants to specific community resources, including a free 12-week physical activity program. However, some models, including the Integrated Care Service and the Satir Model with Motivational Interviewing techniques, did not directly provide connections to community resources. This table emphasizes the varying degrees to which elderly care models integrate community resource connections into their care strategies.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 7. Community support as a component of a model.\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eTable 8 summarizes the methods used to evaluate outcomes across various elderly care models. Some models, like the Integrated Care Service, used specific tools such as the IPOS to measure Quality of Life, while others, like the Community Geriatrics Unit, focused on hospitalization rates and emergency visits. CAPABLE assessed ADL performance pre- and post-intervention, and the VA-GRACE model tracked readmissions and mortality. Several models, like the Satir Model, used interviews and questionnaires, while others, such as the Specialist Health and Social Care Multidisciplinary Team, applied established evaluation frameworks. In contrast, some models did not provide detailed evaluation methods, highlighting a mix of approaches to assessing outcomes in elderly care.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 8. Method of Evaluation of Outcomes as a component of a model.\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEmerged themes from studies reviewed:\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eProactive Multidisciplinary Care Intervention:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe found that community-based healthcare models that utilized an anticipatory model of care providing multidisciplinary care services had high efficacy at improving overall wellbeing and quality of life for older adults with frailty at two to four weeks and this improvement was sustained at three months (5). To measure well-being in this specific study, they used the Integrated Palliative care Outcome Scale (IPOS) as well as a Comprehensive Geriatric Assessment (CGA)-based intervention and multi-modal interventions to improve health outcomes (5). The intervention consisted of an integrated care service with a specialized team of geriatricians, general practitioners, nurse practitioners, pharmacists, occupational therapists, social workers, physiotherapists, caregiver supports, and volunteers at a purpose-built community center compared to a control group receiving routine care at their primary care provider. Future studies need to be performed to explore this service’s effectiveness on other frailty-related outcomes, such as dependency and hospitalization. Silva-Smith et al. (2011) determined the effectiveness of a proactive primary care program on acute hospitalization and aged-residential care placement for frail older people (6). Patients received primary healthcare-based, RN-level comprehensive geriatric assessment, goal setting, care planning, and regular follow-up, along with self-management education, health and social care navigation, and transitional care for hospital discharges (6).\u0026nbsp;Aged-residential care placement was significantly lower over the first year compared to matched controls\u0026nbsp;(6). There was no significant difference in acute hospitalizations per year. Utilization of supportive service use like allied health therapists based on assessment for social support increased while Emergency Department-based care decreased\u0026nbsp;(6).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eChronic Care Model\u003c/strong\u003e:\u003c/p\u003e\n\u003cp\u003eVestjens\u0026nbsp;(2018) aimed to assess the implementation of interventions guided by the Chronic Care Model (CCM) and evaluate the perceived quality of primary care among practices utilizing the Finding and Follow-up of Frail older persons (FFF) integrated care approach (7). The intervention group of primary care physicians used the Assessment of Chronic Illness Care Short version (ACIC-S) and implemented significantly more interventions compatible with the CCM (7). The study demonstrated that the FFF approach can enhance the quality of primary care for frail older individuals according to healthcare professionals, highlighting its potential as a proactive integrated care model to address the challenges posed by an aging population and reduce pressure on healthcare systems.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSatir Model and Motivational Interviewing Techniques\u003c/strong\u003e:\u003c/p\u003e\n\u003cp\u003eJuthavantana (2021) used an integrative counseling program in a Thai nursing home setting. They utilized the Satir Model and Motivational Interviewing techniques (8). The program significantly improved active aging scores, highlighting the importance of activities, group facilitators, and the group atmosphere, suggesting that psychologists and multidisciplinary teams can utilize this program to support and promote active aging in nursing home residents (8).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCommunity Geriatrics Unit\u003c/strong\u003e:\u003c/p\u003e\n\u003cp\u003eDi (2021) compared integrated home 24/7 call service and coordinated follow-up care (provided by a community geriatric unit) in the intervention group to those receiving routine primary care (PCP) visits (9). Although the number of hospitalizations was like that in the control group, the intervention group had lower cumulative incidence for the first hospitalization after the first year of follow-up. Additionally, there were less frequent unnecessary hospitalizations, lower cumulative incidence for the first emergency room visits, and death occurred more frequently at home. This suggests that providing coordinated care at home can effectively prevent avoidable hospital admissions and improve outcomes for frail older adults, enhancing their quality of life and optimizing healthcare resource utilization (9).\u003c/p\u003e\n\u003cp\u003eEricsson (2005) provided Comprehensive Geriatric Assessments (CGA) using a geriatric mobile geriatric team (GerMoT) (10). This paper investigated the patient's perspective about being in the intervention group and found that the intervention group found the care easily assessable and provided by health professionals who knew them as a person. The CGA-based care in community-dwelling older people showed promising results and participants in GerMoT found the care was making them feel secure and safe (10). The participants thought the care was easily assessable and that providers knew them as people. Accessibility is also an issue in rural communities. ISU Senior HealthMobile partnered with the Area V Agency on Aging and assisted with community building, interagency coordination, and access to senior centers and the community process (11). The study addresses the challenges faced by older adults residing in rural communities, such as limited access to healthcare services and a lack of specialized resources (11). These factors often result in health disparities and reduced quality of care for this population. Overall, the paper highlights the potential of mobile service provision to address the unique needs of rural older adults and promote interdisciplinary practice.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eInformal Caregivers Involved in Shared-Decision Making\u003c/strong\u003e:\u003c/p\u003e\n\u003cp\u003eAdekpedjou (2020) presents the results of a study that explores the impact of involving caregivers in health-related housing decisions for older adults with cognitive impairment (12). They suggest that including caregivers in the decision-making process leads to improved housing outcomes and enhances the overall well-being of older adults in this population (12).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eInterprofessional Education\u003c/strong\u003e:\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003e\u003cstrong\u003eIMPACT (Interprofessional Model of Practice for Aging and Complex Treatments):\u003c/strong\u003e\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003eBell (2011) highlights the collaborative approach taken by the primary care team in managing the health of the geriatric patient (13). It emphasizes the importance of interdisciplinary collaboration and coordination among healthcare professionals to provide comprehensive care (13). Especially in complex geriatric patients, an interdisciplinary team with appropriate follow-up to their primary care provider is essential. They highlight the importance of understanding the limitations and abilities of the care providers to improve the patient's condition. Overall, the paper demonstrates the effectiveness of an interprofessional primary care team in addressing the complex healthcare needs of geriatric patients. It highlights the value of collaboration, shared decision-making, and a holistic approach to enhance patient outcomes and quality of care (13).\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003e\u003cstrong\u003eTraining Multi-Disciplinary Healthcare Students for Supporting Healthy Aging\u003c/strong\u003e:\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003eHenshall (2013) implemented an interprofessional education approach via an educational event held at the University of Birmingham and University Hospital Birmingham. This was a two-day summer school for healthcare students (14). They found that key learning point for students was the need for better awareness and communication by healthcare professionals as to what services are available to older members of the community and the opportunities available for integrated working.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCommunity Aging in Place-Advancing Better Living for Elders (CAPABLE)\u003c/strong\u003e:\u003c/p\u003e\n\u003cp\u003eThe Szanton (2014) study aimed to study the impact of the Community Aging in Place, Advancing Better Living for Elders (CAPABLE) on activities of daily living (ADLs) in adults aged 65 and older living alone (15). That study found that use of the CAPABLE program is associated with a reduction in the disability of low-income older adults dually eligible for Medicare and Medicaid who are living in the community. Another study found that in all six trials of the CAPABLE program, significant enhancements were observed in activities of daily living (ADLs) and instrumental activities of daily living (IADLs), although outcomes differed across studies (16). Utilizing a lower dosage than the original protocol yielded reduced benefits. Moreover, the analysis of four studies assessing costs demonstrated that implementing CAPABLE resulted in cost savings exceeding the implementation expenses (16). During the COVID-19 pandemic, the methods were modified to include COVID-19 precautions and implementation of the CAPABLE program during the COVID-19 pandemic resulted in significant improvements in functional outcomes, instrumental activities of daily living (IADLs) independence, readiness to change, self-reported health status, and depressive symptoms among older adult participants (17). Finally, one study found that to support aging in place and accommodate the growing older adult population, healthcare policy should consider removing payment barriers to nursing care at home and prioritize cost-effective alternatives to institutional care, emphasizing the need for inter-professional strategies like CAPABLE to enhance functional ability\u0026nbsp;(16, 18).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCommunity Pharmacists\u003c/strong\u003e:\u003c/p\u003e\n\u003cp\u003eBerenbrok (2020) examines the frequency of encounters with primary care physicians compared to visits to community pharmacies among Medicare beneficiaries (19). The findings indicate that Medicare beneficiaries have more encounters with community pharmacies than with primary care physicians (13 vs 7) (19). It highlights the significance of community pharmacies as accessible healthcare resources for medication-related services and consultations. Overall, the paper sheds light on the utilization patterns of Medicare beneficiaries, highlighting the higher frequency of visits to community pharmacies compared to encounters with primary care physicians (19). It underscores the importance of leveraging community pharmacies as integral components of the healthcare system to provide comprehensive care and support to older adults.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eVA-GRACE\u003c/strong\u003e:\u003c/p\u003e\n\u003cp\u003eThe Schubert (2022) study evaluated the VA Geriatric Resources for Assessment and Care of Elders (VA-GRACE) program's effect on mortality and readmissions, as well as patient, caregiver, and staff satisfaction (15). Widespread deployment of programs like VA-GRACE will be required to support the Veteran population to age in place. The Geriatric Resources for Assessment and Care of Elders (GRACE) program is a collaborative, multidisciplinary care model which provides home-based geriatric care management. In a randomized controlled trial, GRACE improved quality of care and reduced healthcare utilization compared to usual care (15).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eModel of Career and Technical Education: Skills for Health Aging Resources and Programs (SHARP)\u003c/strong\u003e:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eFrank (2022) study evaluated a career and technical education program that aimed to prepare the workforce for healthy aging programs. They performed a multiyear evaluation with data collected at baseline, midpoint of the program, post-program, and follow-up between 9- and 12-months addressing outcomes at four levels: program, college, faculty, and student (20). There was a significant increase in all four of the items related to EBHP (evidence-based health promotion) and disease management (history of EBHP, documented positive outcomes of EBHP programs, delivery system, specific EBHP model programs) (20). All 13 competencies showed a significant difference between pre and post (20). SHARP addresses aging service educational deficits and supports the growth of EBHPs through workforce preparation (20). This represents the first-ever reported evaluation of a college-level training program in EBHP community-based program delivery for older adults (20).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCare Chain Frail Elderly (CCFE)\u003c/strong\u003e:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe Care Chain Frail Elderly (CCFE) program is a person-centered, integrated service, and community-based care service (21). Hoedemakers (2022) study found that the CCFE is the preferred way of delivering care to frail older adults at six months according to multicriteria decision analysis (MCDA). At 12 months, MCDA results showed little difference from the perspective of patients, informal caregivers, and professionals while payers and policymakers seemed to prefer usual care. The findings of the study shed light on the efficacy of the value-based person-centered integrated care approach in improving the quality of life, health outcomes, and satisfaction levels of frail older adult individuals living at home.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eLuton Framework for Frailty (LFF) and Implementation of an integrated care service for older people with different frailty levels (OPDFL)\u003c/strong\u003e:\u003c/p\u003e\n\u003cp\u003eThe Khan (2023) study concluded that LFF is a promising initiative and lessons learned are likely transferrable to other settings as proactive management of frailty takes on greater policy prominence in the UK and worldwide (22). LFF supports older people with healthy aging to remain in their homes as long as possible. LFF promotes healthy aging, identifying frail older adults, proactively manages their care, and reduces the need for those aged over 65 to be urgently admitted to the hospital (22). This study's conclusion highlights the in-depth qualitative analysis of an integrated care program for older people with frailty (OPDFL) and identifies factors influencing its implementation. The findings suggest that involving older people in the design of interventions is crucial for their success, and the development of multidisciplinary teams (MDTs) is beneficial for managing complex cases\u0026nbsp;(22). However, further evaluation is needed to understand the variations in MDT implementation. Additionally, establishing common data systems for both primary and secondary care is recommended\u0026nbsp;(22).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eHealth Teams Advancing Patient Experience: Strengthening Quality (Health TAPESTRY)\u003c/strong\u003e:\u003c/p\u003e\n\u003cp\u003eHealth Teams Advancing Patient Experience: Strengthening Quality (Health TAPESTRY) is a primary care intervention aimed at supporting older adults that involves trained volunteers, interprofessional teams, technology, and system navigation (23). Valaites’ (2020) paper examines implementation of Health TAPESTRY in relation to interprofessional teamwork including volunteers (23). This study concluded that regular communication among all team members, the development of procedures and/or protocols to support team processes, and ongoing review and feedback are critical to implementation of innovations involving primary care teams (23).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePatient-Centered Integrated Model of Home Health Care Services in South Korea (PICS-K)\u003c/strong\u003e:\u003c/p\u003e\n\u003cp\u003eMun (2020) PICS-K has six main features: integration of primary care-hospital-personal care-social services through a consortium, home health support center (HHSC) in hospitals with primary care collaboration, increased accessibility, interdisciplinary team (IDT), patient-centeredness, and education (24). The National Health Insurance Service (NHIS) established an IDT home health support center in a public hospital in August 2021 (24). They performed a case study of the first year of the initiatives. NHIS is considering a home healthcare model for implementation based on the results of these initiatives that can be applied nationwide (24). The importance is that PICS-K is an appropriate model for nationwide implementation, but the authors list numerous steps that must be taken first like regional hospitals having existing PCPs performing home visits, building of home healthcare centers in primary care clinics (24).\u0026nbsp;\u003c/p\u003e\n\n\n\n\n\n\n\n\n\n\n\n"},{"header":"Discussion","content":"\u003cp\u003eThe themes that emerged from the reviewed studies highlight various proactive and integrated care interventions aimed at improving the wellbeing and quality of life of older adults (5-7, 16, 18, 25). Community-based studies involving multidisciplinary care services demonstrated sustained improvements in overall wellbeing and quality of life for frail older individuals (5, 7, 12, 26, 27). Additionally, comprehensive geriatric assessments, goal-setting, and regular follow-up interventions have shown promising results in reducing aged-residential care placement and unnecessary hospitalizations (6, 10, 22, 23). Implementing interventions guided by the Chronic Care Model has proven effective in enhancing the quality of primary care for frail older individuals, showcasing its potential as a proactive integrated care approach (7). Moreover, the use of integrative counseling programs, such as the Satir Model and Motivational Interviewing techniques, has significantly improved active aging scores among older adult populations in nursing homes (8). Collaborative efforts by community geriatrics units and the involvement of caregivers in shared decision-making have also shown positive outcomes, including reduced avoidable hospital admissions and improved housing outcomes for older adults with cognitive impairment (9-11).\u003c/p\u003e\u003cp\u003eInterprofessional management teams have proven valuable in managing the complex healthcare needs of geriatric patients, emphasizing the significance of collaboration and a holistic approach to enhance patient outcomes and quality of care (4, 13, 25, 28, 29). Similarly, initiatives like the Community Aging in Place-Advancing Better Living for Elders (CAPABLE) have demonstrated significant reductions in disability and functional improvements in older adults living in the community, indicating the potential for cost-effective alternatives to institutional care (16-18, 25, 30).\u003c/p\u003e\u003cp\u003eCommunity pharmacists play a vital role in providing accessible healthcare resources for medication-related services and consultations for older adults (19). The VA Geriatric Resources for Assessment and Care of Elders (VA-GRACE) program and the Model of Career and Technical Education: Skills for Healthy Aging Resources and Programs (SHARP) have shown promising results in improving care management and enhancing the growth of evidence-based health promotion programs for older adults (15, 20).\u003c/p\u003e\u003cp\u003eThe Care Chain Frail Elderly (CCFE) program has proven effective in providing person-centered, integrated care services for frail older adult individuals living at home (21). Furthermore, initiatives like the Luton Framework for Frailty (LFF) and Health Teams Advancing Patient Experience: Strengthening Quality (Health TAPESTRY) demonstrate the importance of interprofessional teamwork, regular communication, and feedback in implementing innovative primary care interventions (22, 23).\u003c/p\u003e\u003cp\u003eOur comprehensive review, as illustrated in Table 4-8, examined a range of healthcare models designed for the geriatric population, evaluating their coverage of essential older adult care aspects: physical, mental, and social health, alongside community support. A salient feature across the models was the integration of interprofessional teams, which are critical for delivering holistic geriatric care. The analysis also focused on the presence of structured outcome evaluation methods, which are crucial for verifying the effectiveness and guiding the refinement of care services. All these features appear to be crucial when answering the question: what makes a good model of care? Hence, based on the evidence from this review, we believe that a good model of care should include the following but not limited key elements: interprofessional collaboration, comprehensive geriatric assessments (CGA) with goal setting, proactive and preventive care, and community-based, accessible care.\u003c/p\u003e\u003cp\u003eFrom the data in Tables 5-8, it became clear that most healthcare models encompassed many if not all key elements of integrated care delivery. \u0026nbsp;One key element of this was addressing a participant’s physical health (31). It is critical that older persons maintain their physical well-being to live healthy lives and prevent age-related health issues (31). Mental health is another key element that must be addressed in a model of care (32). Addressing people’s social health is essential as social participation is linked to several benefits such as better sleep, better cognitive function, and lower levels of depression (33-36). The consistent and unanimous inclusion of various health aspects and the application of an interprofessional approach indicate a comprehensive understanding of the multifaceted nature of geriatric care within the field. Furthermore, the widespread implementation of outcome evaluation mechanisms suggests a commitment to ongoing improvement and accountability in older adult care models (5, 7, 8, 10, 15, 16).\u003c/p\u003e\u003cp\u003eOur analysis, however, reveals significant gaps in knowledge concerning the rural older population and their access to healthcare services and health outcomes. Despite advancements in healthcare, there remains a scarcity of comprehensive studies and data specifically focused on rural older adults. Existing research tends to predominantly concentrate on urban or suburban populations, inadvertently overlooking the unique challenges faced by those residing in rural areas.\u0026nbsp;\u003c/p\u003e\u003cp\u003eLife expectancy in the U.S. is inversely related to rurality, with those in large metropolitan areas enjoying higher life expectancy (79.1 years) compared to residents of small towns (76.9 years) and rural areas (76.7 years) in 2005-2009. Over four decades, the disparity between rural and urban areas widened, with the life expectancy gap increasing from 0.4 years in 1969-1971 to 2.0 years in 2005-2009. Notably, rural poor and rural black populations now have life expectancies comparable to urban populations from forty years ago. The key causes of death driving these disparities include heart disease, unintentional injuries, COPD, lung cancer, stroke, suicide, and diabetes, highlighting the urgent need for targeted healthcare interventions in rural areas (37).\u003c/p\u003e\u003cp\u003eOlder adults in rural areas face significant disparities in health outcomes compared to their urban counterparts (38). Between 1999 and 2019, rural areas consistently had higher age-adjusted mortality rates (AAMRs) than urban areas (38). For example, while AAMRs in large metropolitan areas decreased from 861.5 per 100,000 to 664.5 per 100,000, in rural areas, they only decreased from 923.8 per 100,000 to 834.0 per 100,000 (38). This disparity grew over time, with the gap in AAMRs between rural and urban areas more than doubling during this period (38). Additionally, rural older adults tend to have poorer health outcomes, with higher rates of chronic diseases, such as heart disease and diabetes, and face more significant barriers to healthcare access, contributing to lower life expectancy and overall poorer health outcomes (39).\u003c/p\u003e\u003cp\u003eLimited access to healthcare facilities, healthcare providers, and specialized services in rural regions has resulted in disparities in health outcomes for older individuals (40). Additionally, the intricate interplay of social determinants, such as transportation barriers, socioeconomic status, and geographic isolation, further exacerbates the healthcare disparities experienced by this population (40). Understanding these gaps is crucial for developing targeted interventions and policies that address the specific needs of rural older adults, ultimately promoting equitable access to quality healthcare and improved health outcomes for this vulnerable demographic.\u003c/p\u003e\u003cp\u003eIn conclusion, the reviewed studies emphasize the effectiveness of proactive and integrated care interventions in enhancing wellbeing, quality of life, and overall healthcare outcomes for older adults. These findings underscore the importance of collaborative efforts, interdisciplinary approaches, and person-centered care models to address the unique needs of the aging population and promote healthy aging in different healthcare settings. Implementing such interventions can optimize healthcare resource utilization and improve the quality of care for older individuals. However, further research and evaluation are needed to explore their impact on other frailty-related outcomes and to better understand the variations in implementation across urban and rural contexts.\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eIn conclusion, the analysis of current literature underscores the significant benefits of proactive, integrated care interventions that are tailored to the geriatric population. These interventions, as evidenced by improvements in well-being, quality of life, and healthcare outcomes, validate the need for collaborative, multidisciplinary approaches centered around the patient. The research notably highlights the critical role of interprofessional teams and outcome evaluations in enhancing geriatric care. However, our review also uncovers a crucial deficiency in our understanding of the healthcare challenges faced by rural older adults, signaling a call for targeted research and tailored strategies to mitigate disparities in this demographic. As the healthcare landscape evolves, the importance of adaptable, person-centered care models grows, promising improved care quality for older adults. To foster this advancement, further studies are necessary to deepen our grasp of the effectiveness of these interventions across varied populations and settings.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eCAPABLE (Community Aging in Place\u0026mdash;Advancing Better Living for Elders)\u003c/p\u003e\n\u003cp\u003eCCM (Chronic Care Model)\u003c/p\u003e\n\u003cp\u003eCCFE (Care Chain Frail Elderly)\u003c/p\u003e\n\u003cp\u003eDGIP (Dutch EASYcare Study Geriatric Intervention Program)\u003c/p\u003e\n\u003cp\u003eFFF (Finding and Follow-up of Frail older persons)\u003c/p\u003e\n\u003cp\u003eGerMoT (Geriatric Mobile Team)\u003c/p\u003e\n\u003cp\u003eHealth TAPESTRY (Health Teams Advancing Patient Experience: Strengthening Quality\u003c/p\u003e\n\u003cp\u003eIMPACT (Interprofessional Model of Practice for Aging and Complex Treatments)\u003c/p\u003e\n\u003cp\u003eLuton Framework for Frailty (LFF)\u003c/p\u003e\n\u003cp\u003ePICS-K (Patient-Centered Integrated Model of Home Health Care Services in South Korea)\u003c/p\u003e\n\u003cp\u003eSDM (Shared-Decision Making)\u003c/p\u003e\n\u003cp\u003eSHARP (Skills for Health Aging Resources and Programs)\u003c/p\u003e\n\u003cp\u003eVA-GRACE (Veteran\u0026rsquo;s Affairs Geriatric Resources for Assessment and Care of Elders)\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll included sources were from trustworthy, peer-reviewed, and database indexed publications. Articles included via hand searching were not indexed in the four databases searched explicitly but were available elsewhere. IRB approval was not sought for this project as all included studies had already obtained IRB approval.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAlthough using studies published in peer-reviewed journals helps ensure quality, it also\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eintroduces the potential for publication and reporting bias, limiting the generalizability of the results. This may limit representation from studies with null or negative findings since studies with positive findings or higher satisfaction rates may be more likely to be published or submitted for publishing, potentially skewing the results.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eData sharing is not applicable to this article as no datasets were generated or analyzed during the current study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNo funding was attained to support this research.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eClinical trial number\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026apos; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003ePW, YG, and JP engaged in the conception and design of the work. PW and YG did the acquisition, analysis, and interpretation of data. PW and YG initially drafted the work, and AF substantively revised it and prepared the manuscript for submission. JP provided mentorship and oversight and will serve as corresponding author.\u003c/p\u003e\n\u003cp\u003eAll authors have approved the submitted version of this manuscript and agreed both to be personally accountable for their own contributions and to ensure that questions related to the accuracy or integrity of any part of the work, even ones in which they are not personally involved, are appropriately investigated, resolved, and the resolution is documented in the literature.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003eClegg A, Young J, Iliffe S, Rikkert MO, Rockwood K. Frailty in elderly people. 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World Psychiatry. 2022;21(3):336-63.\u003c/li\u003e\n \u003cli\u003eChen JH, Lauderdale DS, Waite LJ. Social participation and older adults\u0026apos; sleep. Soc Sci Med. 2016;149:164-73.\u003c/li\u003e\n \u003cli\u003eBowling A, Pikhartova J, Dodgeon B. Is mid-life social participation associated with cognitive function at age 50? Results from the British National Child Development Study (NCDS). BMC Psychol. 2016;4(1):58.\u003c/li\u003e\n \u003cli\u003eKotwal AA, Kim J, Waite L, Dale W. Social Function and Cognitive Status: Results from a US Nationally Representative Survey of Older Adults. J Gen Intern Med. 2016;31(8):854-62.\u003c/li\u003e\n \u003cli\u003eCroezen S, Avendano M, Burdorf A, van Lenthe FJ. Social participation and depression in old age: a fixed-effects analysis in 10 European countries. Am J Epidemiol. 2015;182(2):168-76.\u003c/li\u003e\n \u003cli\u003eSingh GK, Siahpush M. Widening rural-urban disparities in life expectancy, U.S., 1969-2009. Am J Prev Med. 2014;46(2):e19-29.\u003c/li\u003e\n \u003cli\u003eCross SH, Califf RM, Warraich HJ. Rural-Urban Disparity in Mortality in the US From 1999 to 2019. JAMA. 2021;325(22):2312-4.\u003c/li\u003e\n \u003cli\u003eCohen SA, Greaney ML. Aging in Rural Communities. Curr Epidemiol Rep. 2023;10(1):1-16.\u003c/li\u003e\n \u003cli\u003evan Gaans D, Dent E. Issues of accessibility to health services by older Australians: a review. Public Health Rev. 2018;39:20.\u003c/li\u003e\n \u003cli\u003eEconomic UNDoI, Economic UNDf, Analysis P. World population prospects: United Nations, Department of International, Economic and Social Affairs; 2001.\u003c/li\u003e\n \u003cli\u003eEkelund C, Eklund K. Longitudinal effects on self-determination in the RCT \u0026quot;Continuum of care for frail elderly people\u0026quot;. Quality in Ageing and Older Adults. 2015;16:165-76.\u003c/li\u003e\n \u003cli\u003eFeatherstone A. Developing a holistic, multidisciplinary community service for frail older people. Nurs Older People. 2018;30(7):34-40.\u003c/li\u003e\n \u003cli\u003eInzitari M, P\u0026eacute;rez LM, Enfedaque MB, Soto L, D\u0026iacute;az F, Gual N, et al. Integrated primary and geriatric care for frail older adults in the community: Implementation of a complex intervention into real life. Eur J Intern Med. 2018;56:57-63.\u003c/li\u003e\n \u003cli\u003eRobinson TE, Boyd ML, North D, Wignall J, Dawe M, McQueen J, et al. Proactive primary care model for frail older people in New Zealand delays aged-residential care: A quasi-experiment. J Am Geriatr Soc. 2021;69(6):1617-26.\u003c/li\u003e\n \u003cli\u003eRomera-Liebana L, Orfila F, Segura JM, Real J, Fabra ML, M\u0026ouml;ller M, et al. Effects of a Primary Care-Based Multifactorial Intervention on Physical and Cognitive Function in Frail, Elderly Individuals: A Randomized Controlled Trial. J Gerontol A Biol Sci Med Sci. 2018;73(12):1688-74.\u003c/li\u003e\n \u003cli\u003eSuijker JJ, van Rijn M, Buurman BM, Ter Riet G, Moll van Charante EP, de Rooij SE. Effects of Nurse-Led Multifactorial Care to Prevent Disability in Community-Living Older People: Cluster Randomized Trial. PLoS One. 2016;11(7):e0158714.\u003c/li\u003e\n \u003cli\u003eClark JM, Sanders S, Carter M, Honeyman D, Cleo G, Auld Y, et al. Improving the translation of search strategies using the Polyglot Search Translator: a randomized controlled trial. J Med Libr Assoc. 2020;108(2):195-207.\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003eTables 1 to 8 are available in the Supplementary Files section\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Healthy aging, aging in place, interdisciplinary team, integrated model of care, independent living, intersectoral collaboration, interprofessional","lastPublishedDoi":"10.21203/rs.3.rs-6221967/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6221967/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cb\u003eBackground\u003c/b\u003e\u003c/p\u003e \u003cp\u003eRecent global increases in aging populations have prompted an increased need to provide quality care for older adults, especially older adults who are living with frailty and multiple chronic conditions. A response to this has been implementing innovative and interdisciplinary models of care that focus on the need to enhance older adults\u0026rsquo; quality of life and well-being. Several effective multidisciplinary care services have emerged to address the physical, cognitive, and psychosocial needs of older adults that involve integrated approaches. In this review, we discuss the available integrative models of care and evaluate their effectiveness in providing interdisciplinary interventions for supporting healthy aging, especially with a focus on the rural older adult population.\u003c/p\u003e\u003cp\u003e\u003cb\u003eMethods\u003c/b\u003e\u003c/p\u003e \u003cp\u003e We undertook a literature search for models of older adult care reported between January 2000 and April 2023 that yielded 613 publications regarding proactive multidisciplinary care suited to older adults and their applicability to rural settings. Only 33 publications either focused on rural older adults or were applicable to rural older adults.\u003c/p\u003e\u003cp\u003e\u003cb\u003eResults\u003c/b\u003e\u003c/p\u003e \u003cp\u003eThe results highlighted the effectiveness of proactive multidisciplinary care services in improving overall well-being and quality of life for older individuals. Coordinated home care provided by a community geriatric unit demonstrated the potential to prevent avoidable hospital admissions and improve outcomes for frail older adults. Furthermore, various interprofessional education approaches showcased the value of collaborative efforts and holistic care in addressing the complex needs of geriatric patients.\u003c/p\u003e\u003cp\u003e\u003cb\u003eConclusions\u003c/b\u003e\u003c/p\u003e \u003cp\u003eThis review highlights the powerful impact of integrated care models on the physical and mental health of the aging population, especially by improving the activities of daily living in frail older adults. The success of person-centered approaches and technology in multidisciplinary collaborations was evident. Further research is needed to evaluate patient-centered interventions and the long-term sustainability of integrated care models. Moreover, this review emphasizes knowledge gaps regarding healthcare access and outcomes for rural older adults, emphasizing the need for targeted interventions and policies to promote equitable access to quality healthcare. The findings provide guidance for future research and policy development to improve healthcare services and enhance the overall quality of life for older adults.\u003c/p\u003e","manuscriptTitle":"Integrative Models of Care for Healthy Aging in the Elderly: A Narrative Review","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-04-24 06:54:23","doi":"10.21203/rs.3.rs-6221967/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"d7a2a95f-f1ba-4a48-9aed-709f35a67285","owner":[],"postedDate":"April 24th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-11-18T10:54:12+00:00","versionOfRecord":[],"versionCreatedAt":"2025-04-24 06:54:23","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6221967","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6221967","identity":"rs-6221967","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}