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

Introduction: Older people with multiple chronic conditions have most to gain from successful integrated care models but there is a need to understand current evidence of outcomes for older people. Methods: A qualitative meta-aggregation method was used for the review. Systematic searching of CINAHL, PubMed (Medline), Web of Science, PsycINFO, Scopus and Cochrane identified an initial 93 papers, of which 27 were reviewed. Studies were selected according to the pre-defined protocol and quality assessed using The Joanna Briggs Institute Critical Appraisal Tools (JBIQARI). Eleven, peer-reviewed, English-language papers published between 2000 to 2020 were included. Results: Thirty-three findings were extracted and aggregated into six categories. Three synthesised statements were identified denoting outcomes of integrated care for older people. These indicate social participation and connectedness for older people and their families; the older person feeling motivated to engage in health goals when their preferences were taken into consideration; and older people experiencing support and wellbeing when a therapeutic relationship with a key worker is established. Discussion and conclusion: There was scant evidence of the older person’s voice within included studies and a limited focus on outcomes. Stronger evidence is needed to provide meaningful and robust evaluation of outcomes within integrated care models for the older person.


INTRODUCTION
The concept of integrated care has emerged to address the growing chronic condition burden of global ageing and associated costs of care and delivery implications [1,2]. There is an expectation that moving away from the biomedical model of disease and symptom management to more social and integrated person-centred care models will improve indicators related to wellbeing and healthy ageing [3] and reduce health and social care costs [4].
Integrated aged care is expected to decrease fragmentation by connecting health and social care systems, organisations and services to provide a seamless, continuum of care built around the older person's expressed needs [2]. Much literature concentrates on the integration of various health services, but this review focuses on the integration of health and social care (assistance that provides practical and personal support for people to age in place) using the following definition by Nolte and Pitchforth (2014, p.6).
"Initiatives seeking to improve outcomes for those with (complex) chronic health problems and needs by overcoming issues of fragmentation through linkage or coordination of services of different providers along the continuum of care." Integrated care is often seen as particularly important for older people, who have the greatest number of chronic conditions and comorbidities of any age group [5]. In Australia, between 35 and 60 percent of older Australians have two or more chronic conditions [6,7], with many living in the community with complex disorders such as dementia, sarcopenia and frailty [8]. These require holistic health and social care interventions to enable healthy ageing, wellbeing and quality of life whilst preventing further disability and avoidable admission to acute and long-term care facilities [8,9].
While integrated care models have traditionally had a clear focus on improving health outcomes, social care outcomes have been comparatively overlooked. Social engagement is a known contributor to functional independence and can prevent social frailty cascading into physical and cognitive frailty [10]. Social care services can avert premature transition to residential care [11] or avoidable admission to hospital care [12,13]. Unfortunately, there are few examples of integrated social and health care services [4]. At the micro or individual level, integrated care seeks to improve the quality of care for individual patients, service users and carers by ensuring all services are well coordinated around their needs [14]. Important enablers to the older person's experience of integrated care have been identified as access, information, communication, and coordination, including referrals and care transitions [15]. Low levels of health literacy, particularly for older persons, is a known weak spot in the operationalisation of these enablers [16]. The effects of integrated care are perceived to improve quality of care, increase patient satisfaction and improve access to care, although there is little reported information of outcomes for service uses [17].
While the shift to integrated care was heralded as a panacea to the current fragmented and costly aged care system, it remains unclear whether integrated care has taken place and achieved its goals at the micro level or level of the individual. It is now imperative to examine whether integrated care initiatives are meeting the health and social care needs of older people and what outcomes are being reported. This review addresses the question: "What are the clinical and social outcomes of integrated care for older people, their families and carers?"

METHOD
To address the aim, a systematic qualitative metaaggregation review was conducted by the team following the Joanna Briggs process [18]. The meta-aggregation process is underpinned by pragmatism and aims to generate a set of statements linked in a transparent way to the data to produce practical 'lines of action' and detailed, measurable and specific recommendations for practitioners and policy makers [18]. This review has been registered with Prospero CRD42020192345.

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. 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.
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. Table 1. The majority of the included articles originated from Europe with remaining studies from Australia and Brazil. For this systematic review, eight qualitative papers [21][22][23][24][25][26][27][28], two mixed methods papers [29,30] and one paper using embedded case studies [31] met the inclusion criteria.

Characteristics of included studies are shown in
From the 11 studies, 33 findings were extracted and allocated to six categories based on similarity of meaning (see Appendix B): older people valued social interaction and connectedness; family carers also benefitted from these positive experience as well as from periods of respite; goal setting and encouraging older people to take responsibility for their own improvement; the security, comfort and confidence provided by the home setting; older people can feel excluded from interprofessional communication; and case coordinators are an important source of support for the older person. These six categories were agreed amongst the team and aggregated into three synthesis statements: Older people and families valued social participation and connectedness with others or through engagement with health care providers; The older person felt motivated to engage in health goals when their preferences (e.g. being at home or in a group) were respected; Older people experienced support and wellbeing when there is a therapeutic relationship with a key worker (see Figure 2).

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.

Category 1.1 Social interaction and connectedness
Four of six studies made references to social participation and connectedness [23,26,29]. The ability to meet and  interact socially with others was commented on by both care recipients and their care givers as a key benefit of the integrated care programs beyond the benefits of the "actual exercise" [25]. Older people appreciated the opportunity for social contact with other attendees and the support they received from these relationships, some of which were new, others were longstanding. For example, the following quote is from a senior citizen and informal caregiver: "Many of the women participating in these classes, we were already acquainted with from the past. I met some others during the classes. It is the human relationship, we helped each other." (Senior citizen Pallini and informal caregiver) [29, supplementary file, table S3A].
Additional benefits of connectedness were derived from individual team members being cheerful and friendly and the companionship resulting from the social interactions appear to be key to the success of older people's involvement in specific programs or interventions.
The social aspect was identified as being the "biggest attraction" [25].

Category 1.2 Carers benefit from respite and the older person's positive experiences
Two studies identified the benefit that carers received from the older person's positive social experiences while being out of the home [21,22]. One study reported carers appreciated the older person not being alone, "without company" during the time spent at the coexistence centre and the older person being returned home to family at the end of the day [21]. Another positive outcome described by carers was increased engagement between the family and the older person: "After he began to participate in the coexistence centre, we have even more dialogue among the family. He has more fun […] He got much nicer" [21].

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.
Category 2.1 Facilitating goal setting and encouraging older people to take responsibility for their own improvement Four findings from three studies [23,26,29] supported this category in which the setting of realistic goals relevant to the older person's home setting and where they were encouraged to feel confident in their performance helped older people to take responsibility for activities. Recovery was perceived to be "faster" because of the encouragement by the reablement team providing an implicit patient-reported indicator of a clinical outcome [23].
Category 2.2 Integrated care at home provided a sense of security, comfort, and confidence This category was supported by five findings from three studies [23,28,29]. Receiving visits within the comfort of  home was a key enabler for some older people, creating a sense of autonomy, confidence, and value. In the home setting, the older person felt safe and better understood by care providers [28]. Regaining confidence was a key theme in two studies [23,29] with the perception of the older person exhibiting a "more comfortable and open attitude" also indicating confidence from being on "home turf" [28]. Importantly, being connected to neighbours and the familiar environment of the home was also a contributing factor to the success of the integrated care program [23].

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.

Category 3.1 Older people can feel excluded from interprofessional communication
Communication was seen to be important but sometimes difficult and depending on the strategies used to involve and/or motivate the older person, and the capabilities of the older person to interpret the information, the older person may not always feel involved or prepared in a team environment. "You're sort of unprepared, because you sort of don't know what they want" [28]. Older people also experienced being talked about as one person reported: "Yeah, they talked about all sorts of things, and mostly they talked ABOUT me. (…). She talked up a storm. And so, I responded to what she said. I can't recall what she was asking about" [28].

Category 3.2 Case coordinators are an important support for the older person
This category was represented by 11 findings and several factors were identified to characterise successful outcomes. These included a continuous point of contact in the role of care co-ordinators or case managers who acted as a conduit for information: "The [case manager] is a real source of information for us. We regularly have questions about one thing or the other, and she tries to find answers for us. And she follows up on it too" [27].
The development of ongoing relationships with accessible and flexible care providers contributed to the success of a model or program. The role of the care coordinator/case manager provided the relational continuity which was felt to be key to building trusting and positive relationships when helping older people progress their care goals, as reported: "… she's on a level with you rather than looking down at you, and that alone is worth a lot. And she talks like we do [in dialect], and she's very down to earth. We say she's a good one, and, as my husband says, we wouldn't want to be without her" [27]. For carers too, this point of contact was invaluable: "I wouldn't know who else to contact in the whole process … she [the CNC] was really, really good, she was fantastic -she couldn't have done more for us … I highly recommend her services"[Relative 5]" [30]. This role established rapport and trust: "I trust them. You know, I mean this is the difference. The rapport is totally different with somebody that will listen to the patient than somebody that tells you what you've got to do" [31].
The accessibility and responsiveness of these professionals was highly valued: "You've only got to ring up the surgery and she's here in about 3 minutes if you really need her. She's always here if I badly need her" [31].

DISCUSSION
In examining the findings of the outcomes of integrated care at the individual level for older people, three synthesis statements were developed. These statements provide a rare insight into outcomes that are meaningful to older people, showing that the older person is motivated and engaged by integrated care initiatives that include social needs with more clinical care. Older people value integrated care when it incorporates care coordination, individual choice related to the context of care and goal setting driven by person-centred communication. These findings can inform services globally as they move to increase the intersection between health and social care services through redesign that better meets the needs of the older person.
Initially we had hoped to describe self-reported outcomes of integrated care for older people across multiple health domains; however, physical activity alone was identified [23,25].

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 nonmedical 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].

STRENGTHS AND LIMITATIONS
This is the first paper that specifically looks at the clinical and social outcomes of integrated care outcomes for older people. While there is more research at the microsystem level, the focus of this search at the individual level is extremely important to gauge impacts for the older person, to determine what works best and what quality improvements are necessary. The search did not yield many studies from which to draw out the outcomes under review. We suspect that further studies may be buried within the reablement literature, or literature on person-centred care. What we have captured here is a limited body of research on what the older person, their families and carers have expressed in this field. The limited focus on outcomes for individuals arising from integrated care initiatives makes it difficult to draw strong conclusions about impact.
Further, some of the papers are quite dated (e.g., Lee 2002) which is surprising and may point to a wider definitional problem that has overlooked research in the field.
A more obvious limitation is the lack of research identifying and discussing social care outcomes of integrated care for older people. Social aspects of included studies represented more of an add on to the health services or physical activity program and were not truly holistic in aim.

CONCLUSION
This review found outcomes of integrated care for older people are situated in the positive social interactions within groups or with key workers. The high level of support, information and enabling of the older person through these roles motivated older people to engage in their health goals. Given the importance of these roles to older people, embedding these roles across services, including residential aged care, are recommended.
The limited qualitative data also warrants further research into the clinical and social outcomes of integrated care for older people.

ADDITIONAL FILE
The additional file for this article can be found as follows: • Supplementary data associated with this article can be found in Appendices A and B. DOI: https://doi. org/10.5334/ijic.6469.s1