Implementation and impact of integrated care based on ICOPE pathways - a pilot initiative in Chaoyang District of Beijing

Introduction: In 2015, WHO proposed that the care for older people should be organized based on their intrinsic capacity and functional ability with a comprehensive and integrated approach and published Integrated Care for Older People (ICOPE)pathways and tool kits in 2019. Seven countries were selected for demonstration, with China included. In 2020, with support from WHO and funding from Beijing municipal government, an ICOPE pilot project was implemented in Chaoyang District of Beijing.

Objectives: In China, although the concept of integrated care has been advocated over the past decade, the fragmentation between tertiary and primary care, health and social care is still substantial. There is a lack of implementation pathways, tools and qualified workforce to support care integration. The ICOPE pilot initiative is aimed to explore feasibility of integration mechanisms and ICOPE  applications in context with China policy and cultural environments. 

Target population: A total of 33,504 Chaoyang District residents aged 65 and over were targeted received preliminary screening, among which 7,482 residents were identified with declining intrinsic capacity. After further assessment, 2,148 medium and high-risk residents were recruited and randomized into intervention (n=537) and control groups (n=1,611). In addition to health education received by the control group, the intervention group received various ICOPE intervention measures such as rehabilitation, nutrition improvement and cognitive stimulation delivered by integrated care teams both online and offline. The project was implemented from September 2020 to August 2021.

Highlights: The project was led by a local management team, with experts from tertiary hospitals, community and home health agencies, who played an essential role in coordinating resources across different settings to form integrated care teams, determining payments, performing assessment, delivering needed care and evaluating outcomes. Guided by ICOPE guidelines, an integrated care plan was generated, explained and implemented by the integrated care team, with payment provided on per capita basis directly from the project. A unique feature is the systematic training of the care providers to enable their better understanding of integration concepts and ICOPE implementation. IT system is fully utilized to support real time decision makings and deliver timely interventions. Data were collected at the beginning of the project and six months after. The report showed ADL, physical, mental and nutritional status were improvements for both control and experimental groups, with significantly more improvement for the intervention group.Compared to service utilization for the second half of 2020, 7.7% of less medical visits and 14.3% lower medical expenses were reported.

Conclusions: The study found essential elements for implementation include cross-organizational and cross-disciplinary coordination, system capacity building, standardized practice guidelines, interoperative IT platform, evidence-based data collection and incentivized payment system.  In the future, locally-relevant interventions and innovative payment methods need to be further explored, developed and evaluated in promoting value-based integrated care and healthy aging.