Date Published: October 11, 2018
Publisher: Public Library of Science
Author(s): Andrew M. Briggs, Islene Araujo de Carvalho, Peter Van Bogaert.
Integrated care is recognised as an important enabler to healthy ageing, yet few countries have managed to sustainably deliver integrated care for older people. We aimed to gather global consensus on the key actions required to realign health and long-term systems and integrate services to implement the World Health Organization (WHO) Integrated Care for Older People (ICOPE) approach.
A two-round eDelphi study, including a global consultation meeting, was undertaken to identify, refine and generate consensus on the actions required across high-, middle- and low-income countries to implement the WHO ICOPE approach. In round 1, a framework of 31 actions, empirically derived from previous WHO evidence reviews was presented to panellists to judge the relative importance of each action (numeric rating scale; range:1–9) and provide free-text comments concerning the scope of the actions. These outcomes were discussed and debated at the global consultation meeting. In round 2, a revised framework of 19 actions was presented to panellists to measure their extent of agreement and identify ‘essential’ actions (five-point Likert scale; range: strongly agree to strongly disagree). A threshold of ≥80% for agree/strongly agree was set a priori for consensus.
After round 1 (n = 80 panellists), median scores across 31 actions ranged from 6 to 9. Based on pre-defined category thresholds for median scores, panellists considered 28 actions (90·3%) as ‘important’ and three (9·7%) as ‘uncertain’. Fifteen additional actions were suggested for inclusion based on free-text comments, creating 46 for consideration at the global consultation meeting. In round 2 (n = 84 panellists), agreement (agree or strongly agree) ranged from 84·6–97·6%, suggesting consensus. Fourteen (73·7%) actions were rated as essential.
Fourteen essential actions and five important actions are necessary at system (macro; n = 10) and service (meso; n = 9) levels to implement community-based integrated care for older people.
The global population is ageing more rapidly than ever before–from 2015 to 2050, the proportion of the global population aged 60 years and over will nearly double . This change will happen across high-, middle- and low-income settings, highlighting the need for a realigning health systems to the needs of the older populations they now serve . Population ageing is largely attributed to longer life expectancy, lower fertility rates and increasing prevalence of chronic health conditions, which commonly manifest as multi-morbidities in older people . Many other major social changes are occurring alongside population ageing, for example urbanization and globalization have been accompanied by increased migration, in which younger generations migrate to areas of growth, while older people are left in poorer rural areas without family structures and social safety. Collectively, these issues create new and complex challenges for health and long-term care systems.
Fig 1 summarises the stages and outcomes of the consensus exercise.
While previous literature has synthesised evidence for the components of integrated care approaches for older people and barriers and enablers to their implementation [5, 6], to our knowledge this is the first study to examine the specific actions required to implement integrated care at community level and identify actions needed in systems (macro-level) and services (meso-level) globally. WHO has already undertaken research at the micro level . These data are essential for WHO to take evidence-informed actions in supporting implementation of the ICOPE approach in Member States. In particular, the actions will contribute to improving quality of care for older people, which is critical to achieving universal health coverage . The final set of 19 actions (10 macro-level and 9 meso-level focussed) was strongly supported by the Delphi panel and the construction of the framework deemed highly useful, usable, credible, valuable and appealing according to the User Experience model. The specific actions guide policy makers and service managers to provide integrated care for older people through harnessing community involvement; building capacity in the paid and unpaid workforce; establishing appropriate governance, policy and financing models; prioritising service delivery in community settings; and levering health information and digital systems.