WHO CLINICAL GUIDELINES ON INTEGRATED CARE FOR OLDER PEOPLE

Abstract

Guidelines on community-level interventions to manage declines in intrinsic capacity Why are the ICOPE guidelines needed? Universal health coverage is the foundation for achieving the United Nations Sustainable Development Goal number 3 (SDG 3), for health and well-being. Without considering the health and social care needs of the ever-increasing numbers of older people, SDG 3 will be impossible to achieve. Currently, health systems are often better designed to respond to episodic health needs than to the more complex and chronic health needs that tend to arise with increasing age. There is an urgent need to develop and implement comprehensive and coordinated primary health care approaches that can prevent, slow or reverse declines in intrinsic capacity, and, where these declines are unavoidable, help older people to compensate in ways that maximize their functional ability. Integrated-care approaches should be community-based, designed around the needs of the older person rather than the provider, and coordinated effectively with long-term care systems. What are the ICOPE guidelines? The ICOPE guidelines offer evidence-based direction on: • comprehensive assessment of health status in an older person • delivery of the integrated health care that will enable an older person to maintain their physical and mental capacities, and/or to slow or reverse any declines in these • delivery of interventions to support caregivers. The ICOPE guidelines will assist health care professionals in clinical settings to detect declines in physical and mental capacities and to deliver effective interventions to prevent and delay progression. National guidance will also benefit from drawing on these ICOPE guidelines. The ICOPE guidelines can inform the inclusion of Healthy Ageing interventions in the basic benefits package for pursuing universal health coverage. Services need to be orientated around the needs of older people rather than the needs of the services themselves. Services should respond to a diversity of older people that ranges from those with high and stable levels of intrinsic capacity through those with declining capacity, to people whose capacity has deteriorated to the point of needing the care and support of others. Delivering ICOPE can support a transformation in the way health systems are designed and operate. Important elements of integrated care at the community level are: • a comprehensive assessment and care plan shared with all providers • common care and treatment goals across different providers • community outreach and home-based interventions • support for self-management • comprehensive referral and monitoring processes • community engagement and caregiver support. These recommendations were reached by the consensus of a guideline development group convened by WHO. The group based its decisions on the synthesis of a series of systematic reviews of all the best-quality evidence for the selected domains most relevant to community-level care for older people. The group's consensus was reached with input from a wide range of stakeholders. The full guidelines are available at the WHO website along with supporting documentation, including the evidence profiles developed in the systematic review process.