What are the Clinical and Social Outcomes of Integrated Care for Older People? A Qualitative Systematic Review

Search strategy

This review considered studies that contained qualitative data from any methodology and/or research design and included mixed methods studies with qualitative data as primary data source. We excluded all studies that report quantitative data including mixed methods studies when quantitative data was the primary data source.

Peer-reviewed articles in English from January 2000 to September 2020 were selected. The inclusion criteria were formulated according to the PICO format (Participant, Interest, Context, Outcomes). ‘Participant’ was defined as persons aged 65 years or over or 50 and older if focused on indigenous populations and includes families’ and carers’ perspectives. ‘Interest’ was defined as integrated care at the micro level. ‘Context’ was all settings and eligible population types, or groupings included within the review. Studies captured outcomes related to exercise, cognitive stimulation, and community engagement, for example, as these are all important aspects of healthy ageing and can be found in programs such as reablement programs, and those that have social prescribing as an intervention. This systematic review considered the evidence base using the definition of integrated care by Nolte and Pitchforth (2014) that seeks to improve outcomes for those with complex chronic health problems.

Two researchers (SA, HM) identified the following search terms: Integrated care OR Coordinated care OR Reablement OR Interdisciplinary care OR Integrated service delivery OR Patient-centred OR Social prescribing AND Quality of life OR Health-related quality of life OR HRQOL OR Wellbeing OR Functional OR Social OR psychosocial AND Older people OR Geriatric OR Elderly OR Senior OR 65 years AND Qualitative study OR Mixed-method OR Qualitative Research OR mixed methods study. The use of Boolean Operators was used to access studies.

MR then searched for English language papers on the following electronic databases in consultation with a subject relevant librarian: CINAHL, PubMed (Medline), Web of Science, PsychINFO, Scopus, Cochrane. The search method identified 1203 papers. All identified citations were collated and uploaded to an EndNote library. Duplicates (n = 35) were manually removed prior to selection of studies (Figure 1) by (MR). Titles and abstracts of each citation were then screened against the inclusion criteria by two independent reviewers who were paired for this activity (paired reviewers: CS-HM; MG-SA, SK-HM, KB-PM, JO’B-DM). Studies that met the inclusion criteria were retrieved in full and their citation details imported into the Covidence data extraction tool (licence number 73933), a web-based software platform to assist extraction data for systematic and other research reviews that require screening citations and full text, assessing risk of bias, or extracting study characteristics and outcomes [19]. A full text copy of studies was read in full and assessed against the inclusion criteria. Full text studies that did not meet the inclusion criteria were excluded and reasons for exclusion are included in a Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) flow diagram (see Figure 1) along with the results of the search. Any disagreements that arose between the reviewer pairs was resolved through discussion with another pair from within the review team.

Figure 1

Exclusion criteria:

1. Sample includes wider age range – unable to isolate data for older persons (e.g., mixed aged groups) or data for older persons is not able to be determined

2. Adults between 18 and 65 years or under 50 for indigenous populations

3. ‘Integrated care’ at the meso e.g. service/organisational level, macro/policy e.g. system level or lifespan level e.g. not specific to older people

4. No social component – clinical integrated care only

5. Quantitative data or mixed method papers with quantitative data as the primary data source

6. Language other than English

7. Publications other than peer-reviewed journal articles

Quality appraisal

Eight members of the team worked in pairs to screen the full text of retrieved papers (n = 11) by the JBI Critical Appraisal Checklist for Qualitative Research [18] as shown in Appendix A Critical appraisal results of eligible studies. The checklist consists of ten questions and involved three distinct steps: filtering, technical appraisal, and theoretical appraisal (Hannes and Lockwood, 2011). Papers were included if both reviewers answered ‘yes’ to a minimum of seven of ten prompt questions, with disagreements resolved by consensus after reviewing the criteria. See Appendix A. Critical Appraisal results of eligible studies.

Risk of bias (quality) assessment

The studies included in this systematic review were graded according to the JBI credibility criterion, which demonstrates the congruity between the research question and findings of the studies based on the theoretical frameworks used (JBI, 2014). Each of the included papers were assessed by two members of the research team and any disagreement between reviewers’ judgements were resolved by third members.

Data synthesis

The meta-aggregation process is grounded in pragmatism and transcendental phenomenology [18]. This process requires the findings capture the whole phenomenon of interest to ensure the methodology used for the study is also embedded within these findings and retains the perspective or context provided by the study authors [20]. The findings from included papers, with illustrating quotes, constitute the first step of the meta-aggregation process. Findings are then aggregated into categories according to similarity in meaning. Further analysis of the categories shapes the synthesised statements. Following this process our statements incorporated key factors identified as clinical and social outcomes of integrated care for older people.

Synthesis statement 1: Older people and families valued social participation and connectedness with others or through engagement with health care providers

Social participation and connectedness with others in group activities or through engagement with health care providers provided positive experiences for older people with connectedness being an outcome of integrated care. Two categories supported the first synthesis statement.

Synthesis statement 2 – The older person felt motivated to engage in health goals when their preferences (e.g., being at home or in a group) were respected

When integrated care provided the opportunity to adapt to suit the older person’s preferences, the older person was motivated to participate. Nine findings from two categories supported this synthesis.

Synthesis statement 3: Older people experienced support and wellbeing when there is a therapeutic relationship established with a key worker

Communication involving all stakeholders was integral to successful integrated care outcomes. When the older person was at the centre, communication led to empowerment, feeling in control, and facilitated desired outcomes. Having clear lines of communication with a central person or key worker also facilitated communication. Two categories with 14 findings supported this synthesis.

Older people and families valued social participation and connectedness with others or through engagement with health care providers

These synthesised findings reflect the value of social participation for older people who appreciate either the social aspect of a program or receiving home visits from key workers who are able to see the older person in their home context “as a person who needs support” [23]. Feeling connected, and the enjoyment that this brings, included having fun while involved in physical activity [25]. In the context of increasing and existential loneliness arising in many older people, especially the frail elderly [32], social interaction is a clear outcome of the integrated care activity [25]. Older persons valued meeting others [24, 25], helping some to open up to others [29] as well as helping others to cope with physical impairments or illness [27].

Carers also benefitted from the older person’s positive experiences as they received much needed respite from care provision. Without, primarily, daughters on the frontline of care providing essential support to the older person and integration work, care would not meet the needs of the older person [33].

The older person felt motivated to engage in health goals when their preferences (e.g., being at home or in a group) were respected

Integrated care goal setting motivated older people to work with health professionals [34]. Older people achieve reablement goals if coordinators apply enabling behaviours to empower older people to make “choices” that promote their own wellbeing goals [35].

Older people are more likely to pursue and achieve their goals, when they are involved in their setting as opposed to having these thrust upon them by the health care system [23, 36]. In this way the older person is motivated to take part in a social or physical activity and to take control of this aspect of their care. Asking the older person what they would like to do is an obvious question but none of the papers provided insights into how individual goals were set.

As previously identified, goal plans related to integrated care focus on improving health-related problems and addressing client needs and priorities [34]. However, the older person’s complex needs encompass fear of increasing dependency, decreasing social interaction and a loss of control [27]. Social care interventions may best support or address these needs, although none were identified in this review. Instead, individualised care planning and involvement in decision making appeared to help the older person find purpose [23], which is a strong incentive in combatting the socially stigmatising constructs related to ageism, as well as achieving one’s own goals [37].

In our findings, engagement in physical activity and the location in which this took place was as important to the older people’s health outcomes as the social component. Being outdoors in the natural environment is a positive outcome for older people [23, 25] and evidence shows that being in the outdoor, natural environment provides improvement in overall wellbeing, countering fatigue and poor-quality sleep [38]. The environment provides holistic benefits beyond the program goals of becoming physical fitter or being enabled to mobilise and this includes the value of care being provided in the home setting. A positive outcome of integrated care being provided in the home setting was demonstrated with participants feeling comfortable and secure in this environment [23, 27] as a connection with one’s everyday life made the process more meaningful [23]. A setting that provides comfort, safety and control [39] is as important an enabler of health outcomes as other key enablers, such as a trusted care coordinator and good communication between the team [23].

Older people experienced support and wellbeing when there is a therapeutic relationship with a key worker

The synthesised findings indicated that older people benefited from integrated care that provided clear communication and appropriate information, regular contact with a familiar trusted healthcare provider, individualised care planning and shared decision making [15].

This synthesis statement confirms the important outcomes of providing coordinated integrated care and the pivotal role care coordinators, and case managers have in the lives of older people. Our included studies show how these roles generate trust, provide support and even friendship, as well as enabling access to information, in some cases providing ‘an open line’ when problems arise [31]. This level of responsiveness to the needs of the older person encapsulates the relational, informational and organisational enabling elements of integrated care [15]. Moreover, there is strong link between case coordination and enabling health literacy, especially in the context of multiple chronic conditions. People aged over 65 years and with multiple chronic diseases have been found to experience greater health literacy difficulty than those under 65 years, particularly in engaging with health care professionals, using health services and finding health information [40, 41]. Integrated care may bypass the problems caused by lack of coordination with older people and their caregivers becoming anxious and uncertain about their health care decisions [41].

The level of communication needed to ensure satisfactory service provision is reinforced by family carers who report the input of the interdisciplinary team being of utmost value [22]. Integrated care is able to bring together all stakeholders and reduce fragmentation and within this finding is the evidence that this is happening, albeit in a very limited way.

However, of note, is the inclusion of negative aspects experienced by older people including findings related to unspoken agendas, being talked about, miscommunication and information sharing which were issues identified by older people and health care professionals alike [28, 29]. These highlight the challenges for older people related to multiple stakeholder engagement when they are not central to processes and experience disempowerment. When integrated care includes care coordination the outcome is older people feel more secure, well informed and, ultimately, motivated to keep informed and involved in their own care [15, 42].

Consistent with earlier findings on the limited reported effects of integrated care on service users [17], there is little evidence that integrated care is working well from the older person’s perspective. Importantly, medication management, pain management, quality of life indicators and other vital clinical and social outcomes were not captured in the qualitative findings. There was some evidence of the older person’s lived experience regarding the benefits of integrated care and this has also been described elsewhere [15]. Patient reported outcome measures (PROMs) have an important role in patient-centred health care as these inform care provision. Older people may be encouraged to discuss the physical, psychosocial and non-medical issues leading to improvements in the therapeutic relationship between clinicians and themselves [43]. However, Briggs and colleagues (2018) [44] reported less emphasis on patients’ experiences of care with more interventions focused on service provision. This highlights a gap in the reporting of outcomes at the individual level e.g PROMs and Patient-reported experiences of care (PREMs) which is necessary for quality care that is informed by the older person receiving the care.

Overall, our findings support previous literature that the voice of the older person is not well represented in the research on integrated care [17, 27]. Further, the voice of the growing number of older people above the age of 85 years was especially under-represented. Beyond the community context within which aged care services are provided, residential aged care consumers were also absent from the studies pointing to a lack of opportunity to implement and integrate care in this setting where our oldest old have the most complex health and social care needs, including social isolation, loneliness and high level dependency [32, 45].