An integrated model of community care for older adults: Design, feasibility and evaluation of impact and sustainability

Abstract

Background/Purpose: There is a global movement towards integrated community care; yet this is difficult to implement in countries with well-established separate organizations for health and social care. Such a model requires navigation across rigid boundaries. With philanthropic support, a pilot model of self-financed integrated community care for older people (Cadenza Hub) was established in 2009. Methods: This is a descriptive narrative of a new service model which represents a one stop service from screening for a composite measure of healthy ageing represented by intrinsic capacity in addition to common chronic diseases such as hypertension and diabetes, followed by promotion of activities that retard the ageing process (or frailty prevention) as well as management of other deficits detected (such as vision or hearing problems), to rehabilitation, and Day Care. Evaluation of some components using mixed methods was carried out. Results: The frailty prevention programme was demonstrated to reduce frailty and improve cognitive function, and at the same time was successful in being incorporated into participants regular activities. The Day Care section primarily optimize health and function and support declining function of attendees, as well as provide carer support to enable continuing care at home. Case studies illustrate support in the physical, psychological, functional, nutritional, and social domains. The Centre also facilitated discussions regarding advance care planning. Conclusion: The Cadenza Hub integrated medico social model has the potential to fill a gap in community service for older adults, and address some of the health inequalities arising from unmet needs.