ICT-based person-centered community care platform (IPC3P) to enhance shared decision-making for integrated health and social care services

Development of planning of the integrated care for older people in China: a theory of change approach

BACKGROUND

Integrated Care for Older People (ICOPE), developed by the World Health Organization (WHO) with a global perspective, faces varying degrees of barriers to implementation, particularly in middle-and low-income countries. Therefore, as with other new public service interventions, we draw on established integrated care interventions to design a Theory of Change (ToC) model for ICOPE, and to propose methods and pathways for adapting community-based integrated care models for older people (OP) to specific contexts, thereby updating and enhancing the implementation of ICOPE.

METHODS

An initial ToC for the ICOPE was drafted based on the WHO guidelines and published literature, and synthesizing the results of semi-structured interviews, group discussions. A total of 36 healthcare stakeholder experts in geriatric nursing, geriatric care and chronic disease management, rehabilitation and quality of life, and psychiatric-mental health were recruited to participate in a 5-stage ToC group workshop conducted consecutively. Each workshop has 2-3 facilitators, and lasts from 60 to 120 min. In multiple workshops, the experts discussed the causal pathway, the interventions needed to activate it, the underlying principles and assumptions, evaluated and refined them, and finally reached consensus.

RESULTS

The ToC design has improved the ICOPE program, identifying the resources, long-term outcomes, and impacts required for the implementation of ICOPE in a specific setting, and clarifying the specific components of the integrated care interventions, such as materials, procedures, and intervention providers. The localized, OP-centred model of integrated home care developed in our study may contribute to healthy ageing through four potential long-term outcomes: (1) reduction of unnecessary hospitalizations and increased utilization of referral services, (2) enhancement of self-care capacity to prevent, reverse, or delay the decline of intrinsic capacity in OP, (3) improvement of the quality of life of OP living at home, and (4) reduction of caregiving burdens and improvement in the level of caregiving.

CONCLUSION

The ToC is effective in identifying key characteristics of resources, interventions, impact, and outcomes of integrated care for OP. Our ICOPE program has been strengthened by ToC, which forms an integrated care model for assessment, planning, implementation, and evaluation, adapted to a specific setting, and provides guidance for other areas in similar settings.

Developing an Online Health Community Platform for Facilitating Empowerment in Chronic Disease Prevention and Health Promotion

This study aimed to develop an online health community platform for facilitating the empowerment of people with chronic diseases dwelling in the community regarding disease prevention and health promotion. The user-centered design approach included four main steps: (1) identifying the health problems and needs of target users, (2) developing the content of the platform, (3) constructing the platform, and (4) pilot testing, refinement, and finalization. An online health community platform available both in a mobile application and a Web-enabled application has been launched to facilitate empowerment and self-management by people with chronic conditions. The main components of the application comprised (1) screening for chronic diseases and health problems, (2) setting personal goals for health promotion and action planning to achieve the goals themselves, (3) offering an online health community with shared group goals that help users engage with their peers to attain their goals, and (4) creating one's own online health community and inviting others to participate. The platform has the potential to encourage people with chronic conditions to proactively engage in their own health promotion. Future studies are needed to determine the impact of the application on self-management and empowerment for its users.

DigiHEALTH: Suite of Digital Solutions for Long-Term Healthy and Active Aging

The population in the world is aging dramatically, and therefore, the economic and social effort required to maintain the quality of life is being increased. Assistive technologies are progressively expanding and present great opportunities; however, given the sensitivity of health issues and the vulnerability of older adults, some considerations need to be considered. This paper presents DigiHEALTH, a suite of digital solutions for long-term healthy and active aging. It is the result of a fruitful trajectory of research in healthy aging where we have understood stakeholders' needs, defined the main suite properties (that would allow scalability and interoperability with health services), and codesigned a set of digital solutions by applying a continuous reflexive cycle. At the current stage of development, the digital suite presents eight digital solutions to carry out the following: (a) minimize digital barriers for older adults (authentication system based on face recognition and digital voice assistant), (b) facilitate active and healthy living (well-being assessment module, recommendation system, and personalized nutritional system), and (c) mitigate specific impairments (heart failure decompensation, mobility assessment and correction, and orofacial gesture trainer). The suite is available online and it includes specific details in terms of technology readiness level and specific conditions for usage and acquisition. This live website will be continually updated and enriched with more digital solutions and further experiences of collaboration.

Exploring the Health and Social Needs of Community Residents Using an Online Community Care Platform: Linkage to the International Classification of Functioning, Disability, and Health

Objectives

This study aimed to analyze the outcomes of the Comprehensive Health and Social Need Assessment (CHSNA) system, which identifies community residents’ health and social needs, and to link these needs with the International Classification of Functioning, Disability, and Health (ICF).

Methods

Adult community residents in a metropolitan city in Korea were recruited. They were asked to assess their health and social needs via the CHSNA system, which was integrated into an online community-care platform. Three assessment steps (basic health assessment, needs for activities of daily living, and in-depth health assessment) associated with five ICF components were used to evaluate physical health impairment, difficulties in activities and participation, and environmental problems. The final list of health and social needs was systematically linked to the domains and categories of the ICF. Only data from participants who completed all three assessment steps were included.

Results

Wide ranges of impairments and difficulties regarding the daily living activities, physical health, and environmental status of the community were recorded from 190 people who completed assessments of their health and social needs by the CHSNA system. These participants reported various health and social needs for their community life; common needs corresponded to the ICF components of body functions and activities/participation.

Conclusions

The ICF may be suitable for determining the health-related problems and needs of the general population. Possible improvements to the present system include providing support for completing all assessment steps and developing an ICF core set for an enhanced understanding of health and social needs.