Integrated Oral Healthcare Model for Dependent Older Adults: An Experience-Based Co-Design Approach

Introduction

The global population is aging rapidly, and Thailand is among the nations experiencing a significant demographic shift, with a growing proportion of dependent older adults [1]. In response to the challenges posed by an ageing population, the Thai government has implemented a national policy shift from institutional care towards a Community-Based Long-Term Care (CBLTC) model. This model, developed under the Universal Coverage Scheme, is jointly administered by the Ministry of Public Health and the Ministry of Social Development and Human Security [2]. It focuses on enabling older adults to age in place through the integration of health, social, and community resources. The CBLTC model is regarded as one of Southeast Asia’s most advanced examples of decentralised and intersectoral care [3].

However, despite its integrative framework, the system fails to fully incorporate oral health services. Older adults, especially those who are dependent, often experience significant barriers to oral care access. These include difficulty accessing care due to mobility issues, lack of awareness among caregivers, absence of dental personnel in community-based teams, and unclear service pathways [4]. The result is a high burden of untreated oral disease among this population. National surveys and sub-national studies indicate alarmingly high rates of dental caries, periodontal disease, and tooth loss [5, 6]. These oral conditions not only diminish quality of life but are also linked to adverse systemic health outcomes. Poor oral hygiene has been identified as a modifiable risk factor for aspiration pneumonia, malnutrition, and poor glycaemic control in diabetic patients, conditions that disproportionately affect older adults [7, 8, 9]. Therefore, the exclusion of oral health from Thailand’s CBLTC undermines the very principles of integrated care and represents a critical gap in addressing holistic well-being in this vulnerable population.

Integration of oral healthcare into general health systems is now widely recognised as a global priority. The Lancet Commission on Oral Health has called for radical reform, urging that oral health be incorporated into universal health coverage and treated as an essential component of general health to reduce global inequalities [10]. Similarly, the World Health Organization advocates integrating essential oral health interventions into primary care to achieve people-centred, equitable services [11]. This approach is particularly critical for dependent older adults, whose oral health needs are tightly interlinked with chronic disease management, nutrition, and quality of life.

The neglect of oral healthcare within long-term care systems is not unique to Thailand. Globally, countries have struggled to fully embed dental services into ageing care infrastructures. Many interventions designed to improve oral hygiene among older adults in care settings, such as staff education and the involvement of dental professionals have produced mixed results due to methodological weaknesses and inconsistent outcome measures [12]. These international experiences reflect persistent structural and operational challenges in integrating oral health into long-term care frameworks even in high-income contexts.

Thailand’s CBLTC system has been recognised for its collaborative model involving hospital staff, local municipalities, and community health workers. However, oral health remains excluded from its core operations. Within Laem Chabang Municipality—a semi-urban hub with one of the more developed CBLTC networks—routine dental services are notably absent. Although caregivers acknowledge the importance of maintaining oral hygiene, many often lack the necessary skills, training, and time to provide effective support. There are no embedded dental personnel within the care structure, and referral pathways to professional dental care are not clearly established. Oral health is neither screened nor monitored systematically, and care recipients commonly go without preventive or restorative interventions.

This disconnection between systemic health goals and on-the-ground care delivery reveals a critical service gap. Without the deliberate integration of oral health into Thailand’s long-term care frameworks, the system risks falling short in meeting the holistic needs of its most vulnerable older adults. Addressing this gap requires innovative, contextually relevant models that are designed with, and for, the individuals directly involved in caregiving and service provision.

To address the systemic gap in oral healthcare within Thailand’s CBLTC system, this study adopted Experience-Based Co-Design (EBCD)—a participatory methodology grounded in the principles of Participatory Action Research (PAR). EBCD centres on the lived experiences of service users, caregivers, and professionals, positioning them not merely as informants but as active co-creators in the design of services that reflect real-world needs and constraints [13].

EBCD is especially well-suited to contexts where formal systems exist but fail to achieve meaningful integration or user satisfaction. In Thailand, while the CBLTC has successfully coordinated general health and social care through multi-sector collaboration, oral health remains a neglected domain. This marginalisation is due to structural issues such as the absence of dental personnel, fragmented referral pathways, and unclear role delineation among stakeholders. These challenges mirror broader global patterns in ageing societies, where oral care is often marginalised despite its importance for overall well-being [14]. Traditional top-down healthcare planning has not adequately addressed these challenges, partly because it overlooks the daily caregiving realities and implementation bottlenecks at the community level.

By contrast, EBCD enables a bottom-up, dialogical process through which stakeholders collaboratively identify problems, prioritise feasible interventions, and construct context-appropriate service models. It provides a mechanism for bridging evidence-based guidelines with operational realities, fostering a sense of ownership among those directly involved in care delivery [15, 16]. While EBCD has shown promise in hospital-based service improvement and aged care in high-income settings, its application to community-based oral health initiatives in lower- and middle-income countries like Thailand remains limited and under-documented. This study therefore seeks to expand its utility into this uncharted, yet critically needed, terrain.

To explore the potential of EBCD in this context, This study aimed to co-develop an operational oral healthcare model for dependent older adults that aligns with Thailand’s existing CBLTC system.

Methods

This study employed a Participatory Action Research (PAR) design, with a particular focus on the EBCD methodology. PAR was selected for its commitment to collaborative inquiry and cyclical learning, allowing researchers and stakeholders to jointly investigate and act upon real-world challenges. EBCD, nested within PAR, provides a structured framework to capture the lived experiences of stakeholders and translate them into actionable service innovations.

The EBCD process typically involves six to seven iterative steps, ranging from information gathering through to co-design and evaluation. In this study, we focused specifically on the model development phase, encompassing five sequential steps, as illustrated in the co-designing process framework (Figure 1). These included assessment of oral health status, capturing lived experiences, stakeholder engagement, collaborative co-design, model review and refinement.

Figure 1

The co-designing process was facilitated by the research team and supported by visual and narrative materials from earlier steps (e.g., summary charts, video clips).

Results

Step 5 – Model Refinement and Confirmation

Feedback from this review was minimal and largely supportive. Suggestions focused on minor clarifications in wording and an emphasis on the importance of training and supply availability prior to implementation. These suggestions were incorporated into the final version.

No participant rejected the model or raised substantial objections, indicating a strong level of consensus. Several participants remarked on the collaborative nature of the process:

…“I feel like this is the first time our voice is part of the system.”

– Informal caregiver

…“Now we know our role and how we connect with others—it’s clearer than before.”

– Local health authority representative

The final model was therefore confirmed with full endorsement from all stakeholder groups. While participants acknowledged that real-world application would require ongoing support and refinement, there was broad agreement that this model provided a meaningful and realistic starting point.

All the steps were executed according to the co-designing process framework (Figure 1). The results of each step are summarised in the table below (Table 1).

Table 1

Summary of Results for Each Step of the Co-Designing Process.

STEPS	METHODS	PARTICIPANTS	RESULTS/CONCLUSIONS
1. Assessment of oral health situation	Oral examination and interviewing	Dependent older adults (N = 92)	Poor oral health status but minimally impacted their quality of life
2. Capturing oral care experience	Deep interview with video recording	Dependent older adults (N = 3) and stakeholders (N = 9)	Edited film highlighting real-life oral care experiences of stakeholders, used as a discussion resource.
3. Engaging stakeholders	3 Independent focus group discussion (mainly discussed about each experience and each subgroup ideas of their contribution to oral health of dependent older adults)	3.1 Family care team (N = 6)	The oral care was not prioritised due to general care workload and lack of a referral dentist. Desired roles included performing oral health screenings.
		3.2 Caregivers (N = 8)	Recognised the importance of oral health but were unsure about their skills. They wanted to ensure they could perform oral hygiene care correctly and safely, without causing harm.
		3.3 Local government and private sector (N = 8)	Strong perception of the importance of oral health in CBLTC. The exclusion of oral health was due to the absence of a government-operated dentist. They were willing to provide financial and bureaucratic support for integrating oral healthcare.
4. Co-design oral healthcare service	Focus group discussion	Representatives from previous FCT and caregiver subgroups (N = 8)	The goal was to establish comprehensive oral healthcare for dependent older adults, ensuring emergency dental needs were met, along with regular screenings and quality hygiene care, with caregiver support or independently, as outlined in the final co-designed model (Figure 2).
5. Confirmation of the oral healthcare model	Reviewing	All co-designed members (N = 22)	The final model was shared with all members for a 7-day confirmation period. No rejections were received, indicating unanimous approval.

Upon completing the process, the final co-designed oral healthcare model was established (Figure 2), comprising two distinct components: Pre-Implementation Activities and the Oral Healthcare Model. The Pre-Implementation Activities outlined essential prerequisites preceding the actionable steps, presented in the form of a pyramid-shaped hierarchy. This structure encompassed all stakeholders, delineating their respective roles and responsibilities.

Figure 2

At the foundation of the pyramid, robust support from the local government and corporations served as the initiative’s cornerstone. Their commitment and resources were pivotal to the programme’s success. Ascending the pyramid, formal and informal caregivers appeared next, pivotal in daily oral hygiene care for dependent older adults. Above them were the family care team members, facilitating oral health screening.

Continuing upward, the pyramid’s pinnacle represented the dental team, led by dentists. Here, clinical expertise and academic knowledge converge, providing essential dental care.

The pyramidal model highlighted the essential collaboration among stakeholders, emphasizing their shared commitment to delivering integrated oral healthcare services. Importantly, the shape did not imply a hierarchy of authority but symbolised the convergence of diverse efforts. The programme’s success depended on the collective dedication of all participants.

The model aimed to ensure that all dependent older adults would undergo screenings by the family care team, with emergency cases or those requiring treatment receiving domiciliary dental care provided by a dentist. Daily oral care was assigned to informal caregivers, who would be trained in oral health practices by formal caregivers equipped with specialised training.

Crucially, the pyramidal structure represented unity rather than hierarchy, underscoring the unique contributions of each stakeholder. The stakeholders unanimously endorsed the integrated, co-designed oral healthcare model, affirming its accuracy and readiness for real-world application. Moving forward, the next phase involves implementation the plan to enhance oral healthcare for dependent older adults. This collective endorsement marked a significant step toward improved oral health outcomes for the community.

The EBCD process fostered meaningful collaboration by deliberately addressing power asymmetries between participant groups. By segmenting stakeholders during Step 3 into separate focus groups: family care teams, caregivers, and local authorities, the process enabled participants to contribute without hierarchical pressure. Each group articulated concerns and proposed roles aligned with their real-world capabilities and limitations.

The co-design step (Step 4) further facilitated this inclusivity by synthesising feedback across the three groups, leading to a unified service framework that all participants agreed upon. Informal caregivers felt validated in their contributions, formal caregivers gained clarity regarding their scope of responsibilities, and policymakers recognised gaps in oral care that had previously gone unacknowledged.

Moreover, the model reflects a shift from passive service delivery to proactive engagement. Rather than relying solely on external dental professionals, the model promotes decentralised care anchored in community actors, making integration feasible within existing long-term care pathways. The outcome is not a static service blueprint but a flexible, community-anchored system that can adapt to local conditions while maintaining fidelity to core oral health standards.

As one caregiver shared in the final validation workshop:

…“Before, we didn’t think oral care was something we had to worry about. But when we talked about our role, we realised we are the ones with them every day. If we don’t do it, no one will.”

This reflection underscores the transformative impact of participatory design—not only in shaping services, but also in reshaping stakeholder awareness, ownership, and long-term sustainability.

Discussion

This study provides the first participatory and comprehensive approach to developing an integrated oral healthcare model for dependent older adults within Thailand’s CBLTC system. The integration of oral health into CBLTC has been largely underexplored in Thailand and internationally. This research is notable for employing EBCD, involving stakeholders from multiple levels, including dependent older adults, caregivers, and healthcare professionals. This methodological choice enabled the development of a highly contextual, inclusive, and relevant model of oral healthcare for this vulnerable population. The originality of this study lies in its ability to balance evidence-based guidelines with the lived experiences of those directly involved in care, resulting in a practical and actionable framework for integrating oral health into CBLTC systems.

The primary strength of this research lies in its emphasis on participatory co-design, which fosters collaboration among stakeholders at all levels. EBCD allowed for the involvement of diverse stakeholders, from family caregivers to local government representatives. The need for such participatory models in healthcare systems, especially in the long-term care sector, is well established [17]. As healthcare systems evolve, especially in low- and middle-income countries, the inclusion of end-users, such as caregivers and dependent older adults is crucial for developing solutions that are both feasible and sustainable [18]. This study highlights the value of co-design in addressing systemic gaps that are often overlooked in traditional healthcare approaches. By focusing on community engagement and stakeholder ownership, the study creates a model that is deeply rooted in the local context and responsive to the challenges faced by caregivers and healthcare providers.

The use of EBCD in this study was not without challenges. A key adaptation involved differentiating focus group discussions into three distinct stakeholder subgroups: family care teams, informal caregivers, and local government/private sector representatives. In standard EBCD processes, participants from various backgrounds often engage in mixed-group discussions. However, in our study, power dynamics within the groups were a significant concern. Healthcare professionals, who often possess greater technical expertise, risked dominating the conversation, leaving informal caregivers, who are typically less formally trained, feeling marginalised. Therefore, the co-design process involved subgroup discussions to allow each group to express their views freely without hierarchical pressures [19]. This was crucial for eliciting the unique perspectives of informal caregivers, who are often the primary providers of care but may feel less confident in healthcare discussions [20]. The results of these discussions were then integrated to form a balanced, holistic model that took into account all perspectives.

In alignment with concerns regarding power asymmetries, the research team, comprising dentists, intentionally adopted a facilitative rather than directive role during the co-design process. While dentists were consulted during the preparatory stage, they were purposefully excluded from the core co-design activities. This decision was both methodological and philosophical: it sought to avoid reproducing the top-down dynamics that have characterised previous oral health initiatives. By consciously stepping back, the researchers sought to avoid overshadowing participants’ contributions and to foster a space in which caregivers and community actors could articulate priorities grounded in their own lived realities. The resulting model was thus shaped not by professional assumptions, but by the practical wisdom of those most intimately involved in providing daily care. This participatory stance was essential to promoting ownership, contextual relevance, and long-term feasibility, particularly in light of past guidelines which despite clinical rigour, frequently failed to translate into practice due to insufficient stakeholder involvement during their formulation.

When comparing this model with existing healthcare frameworks, it becomes clear that the participatory approach offers several advantages over traditional top-down models. Existing strategies and models, such as those reviewed by Weening-Verbree et al., rely on standardised protocols and clinical research to guide implementation. While these approaches have proven effective in some contexts, they often fail to account for the unique needs and lived experiences of the populations they serve [21].

In contrast, This co-designed oral healthcare model presents a significant departure from conventional approaches by embedding oral health within Thailand’s CBLTC system. Unlike existing models, this model was co-created with all stakeholders. It prioritises daily care routines, prevention, and community capacity over specialist treatment. This participatory and flexible design not only enhances contextual relevance and ownership but also addresses long-standing barriers to guideline adoption, such as lack of caregiver involvement and impracticality in real-world settings. Table 2 below summarises the key differences.

It is important to emphasise that this model does not seek to replace or diminish the value of conventional clinical protocols, which remain essential in many care settings. Rather, it offers an alternative lens through which oral healthcare can be reimagined, particularly for populations where access to specialist-driven care is limited. By aligning with the principles of community engagement and contextual adaptability, this co-designed model complements existing frameworks and bridges longstanding implementation gaps. In doing so, it adds a new layer of practicality and ownership that enhances—rather than competes with—formal guideline-based approaches.

What sets our co-designed oral healthcare model apart is its community-based approach. A distinguishing feature is its flexibility, as it incorporates feedback from stakeholders in real time and adapts to the community’s specific needs. This approach not only fosters a sense of ownership among stakeholders but also ensures that the model remains responsive to local contexts, making successful implementation more likely. Moreover, the model integrates oral healthcare into existing care pathways, highlighting the importance of multi-sector collaboration in addressing the full range of health needs among older adults.

Despite its innovative approach, this study is not without limitations. One major challenge is ensuring the long-term sustainability of the co-designed model. Given the reliance on trained healthcare personnel, particularly dentists, for domiciliary care, the availability of these resources in rural or resource-constrained areas may pose a barrier.

Additionally, maintaining stakeholder engagement over time is crucial for the success of the model, but may prove difficult without ongoing funding or institutional support. Another limitation is the study’s geographic and demographic focus, conducted in Laem Chabang Municipality, Chonburi Province, which may limit its generalizability to other regions of Thailand or to countries with different healthcare systems.

A key methodological limitation lies in the qualitative nature of the data collected. While qualitative methods, such as interviews and focus groups, provide rich insights into stakeholders’ perspectives, they are also subject to interpretation bias. The small sample size, while ensuring in-depth exploration of stakeholder views, limits the generalizability of the findings. Additionally, the time and resource-intensive nature of the co-design process could hinder the feasibility of replicating this approach in low-resource settings.

The implications of this study for practice and policy are significant. The findings underscore the need to integrate oral healthcare into long-term care systems, particularly in community-based settings. Policymakers and healthcare providers should consider adopting participatory approaches, such as EBCD, to design and implement integrated healthcare models that are context-sensitive and sustainable. By incorporating oral health into the broader framework of long-term care, these models can enhance the quality of life for older adults, reduce the incidence of oral health-related systemic conditions, and ultimately lead to more holistic, person-centred care. This study demonstrates that integrating oral health into long-term care can be achieved through collaboration, stakeholder engagement, and context-specific adaptations, providing a roadmap for future healthcare innovations.

Moving forward, the model developed in this study requires real-world testing and further refinement to assess its effectiveness. Implementation trials, followed by longitudinal studies, will be essential for evaluating the impact of the model on oral health outcomes and the overall quality of life of dependent older adults. Furthermore, adapting the model for use in different cultural and healthcare contexts, both within Thailand and globally, will be crucial for its broader applicability. Policymakers, healthcare providers, and researchers should continue to explore ways to integrate oral health into long-term care systems, particularly in resource-limited settings, to ensure that all older adults receive comprehensive care.

While this study focused on dependent older adults, the participatory principles and methods applied, particularly EBCD, are highly adaptable to other populations and healthcare settings. EBCD and similar stakeholder-driven approaches have been effectively used in areas such as mental health care, maternal health, and chronic disease management [22]. This highlights their potential for addressing service gaps in a wide range of contexts where clinical care may not align well with users lived experiences.

Extending this potential, the co-design approach may offer meaningful benefits for other underserved groups, such as individuals living with disabilities. By centring the voices of those directly affected, community-informed models like the one proposed here provide a practical route toward more inclusive and person-centred healthcare.

Conclusion

Rooted in local wisdom and developed through inclusive collaboration, this study presents a practical oral healthcare model for dependent older adults within Thailand’s CBLTC system. By applying the EBCD framework, the study amplifies the voices of groups often excluded from healthcare planning, including caregivers, dependent older adults, and community-level practitioners. The result is a care model that aligns with both lived experiences and structural service gaps. Although the model has not yet been implemented, it provides a strong foundation for improving equity in geriatric care by positioning oral health as an essential and integrated element within the long-term care continuum.

Reviewers

Nathawut Kaewsutha, DDS, PhD, Department of Pedodontics and Preventive Dentistry, Faculty of Dentistry, Srinakharinwirot University, Bangkok, Thailand.

Margo Reilly, Executive Director, Windsor Family Health Team, Ontario, Canada.

One anonymous reviewer.