Information and Communication Technology Based Integrated Care for Older Adults: A Scoping Review

Background: Integrated care is an important initiative to respond positively to the ageing of society and information and communication technology(ICT) plays an important role in facilitating the integration of functional and normative health and social care. The scoping review aims to synthesize evidence on the experience and practice of ICT-based implementation of integrated care for older adults. Methods: This study followed the research framework developed by Arksey and O’malley for the scoping review and systematically searched for relevant studies published between 1 January 2000 and 30 March 2022 from nine electronic databases, three specialist journals, three key institutional websites, 11 integrated care project websites, google scholar and references of the studies to be included. Two reviewers independently screened and extracted data and used thematic analysis to sort out and summarize the core elements, hindrances and facilitators of ICT-based integrated care. Results: A total of 77 studies were included in this study, including 36 ICT-based practice models of integrated care with seven core elements of implementation including single entry point, comprehensive geriatric assessment, personalized care planning, multidisciplinary case conferences, coordinated care, case management and patient empowerment, which generally had a positive effect on improving quality of life, caregiver burden and primary care resource utilization for older adults, but effectiveness evaluations remained Heterogeneity exists. The barriers and facilitators to ICT-based implementation of integrated care were grouped into four themes: demand-side factors, provider factors, technology factors and system factors. Conclusion: The implementation of ICT-based integrated care for the elderly is expected to improve the health status of both the supply and demand of services, but there is still a need to strengthen the supply of human resources, team training and collaboration, ICT systems and financial support in order to promote the wider use of ICT in integrated care.


INTRODUCTION
The world's population is ageing in an increasingly serious way. In 2019, the global population aged 65 and over has reached 703 million and is expected to exceed 1.5 billion in 2050, and the number of people aged 80 or over will increase from 143 million in 2019 to 426 million in 2050, of which more than 50% will live in East and Southeast Asia [1]. The rapid increase in the proportion of the elderly population has put enormous financial pressure on the national system of elderly service provision. In addition, as older adults age, they are at increased risk of physical and mental decline, with a progressive increase in the prevalence of mobility loss, cognitive decline, hearing impairment and visual impairment, and increasingly complex health and social care needs. However, the World Health Organization (WHO) forecasts a global shortage of 18 million health care workers by 2030, particularly in Africa and South East Asia [2], posing the challenge of maintaining a balance between demand and supply of services for the elderly and the urgent need to find accessible channels to integrate medical and social resources to proactively address the ageing of society.
The United Nations Decade of Healthy Ageing (2020-2030) specifically identifies the development of integrated care as one of the areas of action to ensure that older adults have access to quality basic health services without discrimination [3]. Integrated care refers to the management and provision of services to provide people with continuous health promotion, disease prevention, diagnosis, treatment, disease management, rehabilitation guidance and palliative care throughout their lives and to coordinate care at different levels and locations both within and outside the health sector [4], with the aim of improving the inability of lowquality, inefficient elderly service provision to meet the increasingly complex healthcare needs of older adults. As the 'lubricant' and 'glue' of integrated care systems, the effective use of ICT can increase access to and flow of information, increase work efficiency, improve care integration and management processes, address COVID-19 concerns and social isolation [5], and has been identified as an important enabler of integrated care delivery and coordination of primary health care [6,7].
The World Health Organization has developed the Integrated Person-Centered Health Services (IPCHS) framework and the Integrated Care for Older adults (ICOPE) program, and has developed the ICOPE Handbook application to promote integrated person-centered services based on digital technology [8]. However, most integrated care programs for frail older adults don't follow all WHO-IPCHS strategies and their clinical practice continues to suffer from inadequate resources and support, lack of coordination and interprofessional collaboration, and poor quality of person-centered care [9]. In addition, the adoption of ICT in community-based geriatric care has been slow, and its implementation in integrated care for older adults is often unsatisfactory due to policy, funding and infrastructure factors, with heterogeneity in clinical practice effects [10], and existing studies don't provide an overview of the current state of implementation of ICT-based integrated care for older adults. To fill this gap in the evidence base, this study aims to provide an in-depth analysis and synthesis of the practice models, initial effects, potential barriers and facilitators of ICT-based integrated care for older adults using a scoping review approach, and to draw out policy opportunities and lessons that can be applied to the Chinese context.

METHODS
This study was conducted following the framework of a scoping review developed by Arksey and O'malley [11] and further updated by Levac et al [12], and the study protocol has been published in the BMJ Open [13]. We followed the JBI evidence synthesis manual [14] and the PRISMA-ScR checklist [15] to report the scoping review results.

STAGE 1: IDENTIFYING THE RESEARCH QUESTION
The aim of this study was to summarize the available evidence on the practice models, initial effects, facilitators and hindrances of ICT-based integrated care for older adults. With this research aim in mind, an initial search of the PubMed database was conducted and literature related to the research topic was read. Based on the researcher's initial understanding of the current state of research, a refined research question was formulated following the PCC principles (population, concept, context) [16] as follows.
1 What are the service providers involved in ICT-based integrated care for older adults? What does the ICT used include and what is the functional role it plays? 2 What are the components of ICT-based integrated care services? What are the practice pathways and initial effects? 3 What are the hindrances and facilitators of ICT-based practice of integrated care?

STAGE 2: IDENTIFYING RELEVANT STUDIES
A systematic search of studies published between 1 January 2000 and 30 March 2022 was conducted using a combination of subject headings and entry terms, including "information and communication technology", "Delivery of Health Care, Integrated" and "Aged". Detailed search formulas for each database can be found in the supplementary materials. The search strategy was

STAGE 3: STUDY SELECTION
Title, abstract and full text screening were conducted by two reviewers (TYT and CQY) based on study inclusion and exclusion criteria. Inclusion criteria: (1)the intervention/ target/service population is older adults aged 60 and above; (2)the study describes and/or evaluates ICT-based practice models of integrated care, in which the integrated care need to follow the principles of comprehensiveness, multidisciplinary, and person-centeredness. ICT refers to the various technological tools and resources used to collect, store, retrieve, create, share or transmit information, including computers, the internet, live broadcast technology, recorded broadcast technology and telephony, etc.; (3)the literature is applicable to any type of health care setting, including primary health care, hospitals, emergency departments or medical consortia; (4)quantitative (intervention research, descriptive research, interpretation-prediction-correlation research), qualitative (phenomenology, grounded theory, action research) or mixed-method research designs are used; (5)the language of the paper is English. Exclusion criteria: (1)study of nonhuman subjects; (2)reviews, editorials and descriptive articles that do not provide relevant empirical evidence; (3)literature featuring no access to the full text or incomplete information. Two reviewers (TYT and CQY) searched and reviewed independently, and when there was disagreement about the inclusion of studies, a third reviewer (MLX) was consulted or discussed by the study team for a final decision. The research team developed the data extraction  checklist based on the research questions and the   principles of person-centered, comprehensive and  multidisciplinary nature of integrated care, specifically  author, year, publication name, study title, country,  study design, research questions/objectives, participant  characteristics/sample size, model practice approach,  and model practice evaluation. Tow reviewers (TYT and  CQY) worked independently on the data using a data extraction form, and any disagreements were resolved through discussion in team meetings until consensus was reached.

STAGE 5: COLLATING, SUMMARIZING, AND REPORTING RESULTS
This study used quantitative (descriptive statistical analysis, frequency) and qualitative (descriptive content analysis) methods to analyze the scope, nature and distribution of the included studies and used graphical techniques to iteratively synthesize and interpret the findings by screening and ranking the material. Two researchers (TYT and CQY) followed Braun and Clarke's thematic analysis to sort out and summarize the core elements, barriers and facilitators of integrated care content and used Nvivo software to code and analyze the data.

RESULTS
A total of 30,280 articles were retrieved in this study, of which 25,318 were from electronic databases and 4,962 from three professional journals, and 7,437 duplicates were excluded after preliminary check. After reading the titles and abstracts to exclude literature 22,520 articles, 322 articles were re-screened by reading the full text and further searched for their references, grey literature databases, government and project websites for additions, resulting in 77 studies being included in the review, of which 71 were published, one was grey literature and five were working papers. A flow chart of the screening process is detailed in Figure 1.

INFORMATION AND COMMUNICATION TECHNOLOGY
The CareWell research team defined 12 ICT tools that support integrated care: electronic prescriptions, messaging between clinicians and patients, electronic health records, interconsultation, call centers, virtual conferences, personal health folders, nurse information systems, educational platforms, collaborative platforms, telemonitoring and multichannel centers [37]. We grouped the ICT support for the 36 integrated care practice models in this study into the following ten categories: digital communications(61.1%), electronic health record(33.3%), clinician and patient information system(33.3%), electronic medical record(16.7%), electronic assessment tool(13.9%), wearable monitoring device and sensor (8.3%), personal health folder(5.6%), digital educational material(5.6%), electronic prescription(2.8%), and social robot(2.8%). ICT provide easy access to ongoing monitoring, assessment, management and sharing of patient health information, communication and coordination of care among multidisciplinary team members, and documentation and monitoring of plan performance. In addition, ICT plays an important role in decision aid support, with the Embrace Integrated Care Project team embedding international functional, disability and health classification resources and official guidelines into clinical information systems to support decision-making [19,43,44,64,83,84]. The CareWell Primary Care Project has developed multidisciplinary practice guidelines for medical, nursing and social support for eight common geriatric syndromes, advance care planning practice guidelines, which are embedded in the Health and Wellbeing Information Portal for use as job aids and to promote positive dialogue between frail older adults and GP [85][86][87][88]. The World Health Organization also deliberately launched the ICOPE Handbook application to generate interventions and care plans based on the results of the intrinsic capacity assessment to help implement ICOPE in community and primary care settings [79].

CORE ELEMENTS OF ICT-BASED IMPLEMENTATION OF INTEGRATED CARE
By integrating the operational approach and practice path of 36 practice models, a total of seven core elements of integrated care were identified, including single entry point, comprehensive geriatric assessment, personalized care planning, multidisciplinary case conferences, coordinated care, case management, patient empowerment. ICT was integrated and woven through the process of integrating care, facilitating horizontal and vertical integration to provide easy access to services. The seven core elements are explained below.
(1) Single entry point: A mechanism for health care providers and community-based organizations to provide services to older adults in order to increase coherence and coordination of care, often using primary care practices, health professionals as a single-entry point. Hebert et al [25-27] used a telephone or written referral as an entry point to services for frail older adults based on the Quebec Health Information Line, and after a needs assessment a referral to an integrated care delivery system could be made. The Walcheren Integrated Care Study team used GP as a single-entry point for older adults and their caregivers, health professionals, assessed as frail older adults with access to practice nurse visits [33].
(2) Comprehensive geriatric assessment: Multidimensional assessments of the functional health, care needs and social support of older adults and their caregivers are conducted regularly by members of the multidisciplinary team to identify participant preferences, health problems and optimization issues and generate assessment reports to guide the development of care plans. ICT was used as a vehicle for assessment tools to collect data, create reports, and share results. Delmastro [59] and Piera-Jimenez [38] used smart medical devices and sensors to collect health data on older adults. Malavasi [67] and Doyle [91] used a color-coded traffic light system in an app to customize health and wellbeing data reports for older adults and to send alerts and push messages when values were abnormal.
(3) Personalized care plan: The multidisciplinary team develops, updates and prioritizes the implementation of personalized goals and care plans based on the multidimensional assessment of each older person. Seven practice models of integrated care explicitly proposed the construction of evidence-based care programs based on guidelines and others, providing evidence-based recommendations from multidisciplinary teams [17, 18, 21, 29, 40-42, 48, 50-56, 58, 85-88, 90]. Choi et al [90] suggested that quantitatively tailored evidence-based interventions based on ICT support are facilitators for safeguarding the fidelity of SPEC implementation. ICT provided the vehicle for care plan implementation. The CareWell Primary Care Project team stored evidence-based personalized care plans on the Health and Wellbeing Information Portal website for viewing by members of the multidisciplinary team, with a requirement to revise them at least once every six months [85][86][87][88].
(4) Multidisciplinary case conferences: Regular meetings are organized for members of the multidisciplinary team to review assessment reports on older adults, to develop, implement and adjust care plans, or to discuss complex cases and to integrate ideas from team members to provide health guidance information, in a face-to-face format. However, CareWell primary care team members communicated virtually based on a health and wellbeing information website and met every 4-8 weeks [85][86][87][88]. Rosenberg et al [80] even held daily virtual team meetings, sharing and commenting on progress notes via email. Silsand et al 18 used a video platform for collaborative team meetings, effectively reducing the time for members to attend meetings.
(5) Coordination of care: Based on vertical and horizontal integration to coordinate health and social institutions, medical and social workers, assigning members of multidisciplinary teams to provide services to meet the needs of the elderly. Tourigny et al [28] achieved interdepartmental coordination at strategic, tactical and clinical levels by forming a joint management committee to agree on policy and direction, resource allocation. Pauly et al [93] assigned advanced practice nurses (APNs) to accompany patients and family caregivers on postdischarge visits to primary care providers to coordinate care. ICT-based features such as information sharing and virtual communication also provide facilitated channels for coordinating care.
(6) Case management: A case manager is set up and assigned to each participant in the multidisciplinary team to be responsible for planning, implementing and coordinating the care plan. Colomina et al [49] developed the Smart Adaptive Case Management (SACM) system specifically for care team members to randomly access patient files in order to coordinate professionals in different settings and to establish nurse-patient communication channels where needed. RubiN project practices have also shown that community-based care and case management play an important role in identifying, promoting and preventing family caregiver burden [69,70].
(7) Patient empowerment: Multidisciplinary team members develop an equal patient-care relationship with older adults and their caregivers, encouraging active participation in integrated care practices by stimulating patients' inner potential, empowering them to make more decisions and choices, and sharing disease-related information and knowledge with them. The CareWell integrated care team run the empowerment program KronikOn for frail older adults and their caregivers, where primary and secondary nurses provided basic information to help patients understand their condition in order to explore and agree on the best way to care for themselves [36,37,77,78]. The Personalized Connected Care project used a mobile health self-management system for older adults and informal caregivers to access health information and communicate fully with the care team [49]. The involvement of older adults played an important role in promoting ICOPE implementation.

SERVICE CONTENTS AND PRACTICE EFFECTS OF ICT-BASED INTEGRATED CARE
36 practice models integrated medical and social resources in order to provide a full range of care services. In addition to basic services such as professional medical care (medical treatment, nursing, rehabilitation, psychological counselling, nutritional support, medication and exercise guidance, etc.), primary health care, social support (community resources, volunteer support) and home care, they also provide telehealth (including telemedicine, telemonitoring, telecare and teleconsultation) (30.6%), day care (13.9%), home help (11.1%), caregiver support (8.3%), end-of-life care (8.3%), et al. Colomina et al [49] also customized virtual coaches with automatic feedback for older adults based on health status reports to provide a lively and personalized health education service.

HINDRANCES AND FACILITATORS OF ICT-BASED PRACTICE OF INTEGRATED CARE
ICT plays a key role in all aspects of integrated care, including community resource and policy, health system, delivery system, self-management support, decision support and clinical information system, but numerous factors still hinder the use of eHealth technology. Six studies described barriers to practice ICT-based integrated care [20,23,59,61,79,91], grouped under four themes: demand-side factors (fear and lack of confidence in applying IT, lack of skills of patients, lack of trust in the accuracy of smart monitoring devices), supply-side factors (lack of skills of providers, resistance to innovative applications of IT, lack of human resources), technical factors (inadequate ICT infrastructure, poor compatibility between eHealth tools, inadequate ICT technical support, use of devices and applications process complexity, privacy/security issues), systemic factors (inadequate legislative framework, inadequate funding, uncertainty of cost effectiveness). However, Kastner [20], Vestjens [22] and Valaitis [66] identified adequate human resources, multidisciplinary member involvement, training and regular communication, continuous review and feedback, development of procedures and/or protocols to support team processes, sustainability infrastructure, facilitated ICT systems, clinical leadership involvement, and structured funding as key to guaranteeing the sustainable spread of ICT-supported integrated care models. The active participation of older adults, training of providers, and digital integration of health information were also identified as important facilitators by the World Health Organization in its report on the work of ICOPE Practice [79].

DISCUSSION
The ICT-based integrated care model follows the core elements of single entry point, comprehensive geriatric assessment, personalized care planning, multidisciplinary case conferences, coordinated care, case management, and patient empowerment to provide the services needed for older adults, which preliminary practice has shown to improve physical and mental health and quality of care for older adults, save health care resources, and enhance primary care and community resource utilization, but there is heterogeneity in practice outcomes and numerous influencing factors remain at the demand-side, supply-side, technology, and system levels.
At the demand-side level, the main targets of ICTbased integrated care services are frail older adults (30.6%), older adults with physical or cognitive impairments (16.7%) and older adults with multiple morbidities (13.9%). The increasing prevalence of frailty with age, the consequent deterioration in physical, cognitive, social and psychological conditions, the increasing complexity of health and social care needs, and research showing that multiple morbidities were associated with increased unmet needs, health care utilization and reduced perceived health status and quality of life [94], have a greater preference for integrated care services involving multiple supply actors. Older patients themselves have expressed a desire for accessible, efficient and coordinated care that meets their needs and preferences, while keeping in mind their rights and safety [95]. Islam et al [96] constructed a "Holistic Continuum of Patient Care" program specifically for frail older patients to provide integrated care, and their practice addressed the issue of multiple morbidity.
However, the ICT-based integrated care was hampered by older adults' fear, lack of confidence and skills of using information technology (IT). This may be related to the varying degrees of 'technophobia' among older adults [97], resulting in lower use and acceptance of ICT and indirectly influenced by cognitive closure, resulting in poorer e-health readiness among older adults [98]. This suggests that researchers could subsequently develop training programs and 'age-friendly' information platforms to enhance the acceptance of information technology among older adults, guided by the causes of their 'technophobia'. In addition, the lack of trust in the accuracy of smart monitoring devices among older adults is also a deterrent to participation. However, with the widespread use of IT in healthcare, internet of things(IoT) technologies such as sensors and wearable devices have been identified as a more suitable vehicle for health monitoring and comprehensive geriatric assessment [99], which can effectively improve the ease of data collection and sharing, and the potential benefits of telemonitoring in reducing disease progression and hospitalization in older adults with long-term conditions [100]. The Government can take the lead in placing smart monitoring devices in primary care facilities, providing free application experience for older adults and promoting application on the basis of gaining trust. At the supply-side level, the multidisciplinary team of mainly health professionals, primary care workers and social workers providing services is an important internal driver of integrated care. The involvement of multidisciplinary members helps to meet the complex care needs of older adults and the organization of regular multidisciplinary meetings can help to define the scope of action of members, coordinate care services and is important to improve support for patients and their families, with GPs playing an important role in the successful delivery of care for older adults [101]. In addition, GPs and case managers are often seen as a single point of entry to integrated care. Having a single point of entry facilitates the referral of older adults to appropriate social and/or primary care institutions, it's important for the integration of services and the standardization of the needs assessment process [102], and the single entry system ensures a sufficient volume of patients for financial stability and efficient operation, which helps to ensure that social resources are based on medical needs [103]. It is suggested that researchers could recruit multidisciplinary members to form a service team using the results of a comprehensive assessment of older adults as a guide, making full use of the GP as a single-entry point.
The lack of human resources for services, the lack of skills of providers and resistance to innovative applications of IT are important factors that hinder the implementation of ICT-based integrated care. In 2018, there was a global shortage of approximately 6 million human resources for nurses and a projected demand shortage of 5.7 million nurses remains in 2030, a phenomenon that is particularly evident in the COVID-19 environment, severely impacting the matching of supply and demand for integrated care services [104]. In addition, the IT usage behavior of the multidisciplinary team members, as users of ICT, has a direct impact on the planned implementation and the quality of integrated care. Hector et al. [105] showed that health care assistants perceive ICT to be unhelpful, time-consuming to adopt, burdensome or increasing in workload, which all contributed to resistance to the use of ICT by service providers. This suggests that clinical managers should streamline the process of operating ICT platforms and provide targeted training on ICT applications to strengthen nurses' attitudes and competencies in the use of IT. Healthcare professionals considered that helping to raise awareness of e-health expertise by exposing healthcare professionals to relevant IT solutions and medical technology is the best training initiative to improve their IT skills [106].
Information and communication technologies commonly used in integrated care models included digital communication (61.1%), electronic health records (33.3%), and clinician and patient information systems (33.3%), similar to the results of Melchiorre et al [60] who analyzed the use of e-health tools in European integrated care projects for older adults with multiple morbidities. It can be attributed to that digital communication facilitates timely communication between multidisciplinary teams and with patients, that electronic health records enable the collection and sharing of patient information, and that information systems provide portals to team members and patients in order to empower patients and promote their active participation in the implementation of integrated care [107]. Electronic prescriptions (2.8%) and social robots (2.8%) were less commonly used, which may be related to the fact that ICT-based prescriptions are less frequently issued and transmitted in integrated care services, and that pharmacists make up only 27.8% of the multidisciplinary team members, which, combined with controls on the cost of care, has somewhat influenced the use of e-prescribing and artificially intelligent bots. However, both older patients and their informal caregivers placed a high value on both roboticassisted and non-robotic-assisted technology as a care pathway [108]. In addition, electronic prescription can reduce medication errors and adverse drug reactions, improve prescription safety [109], and pharmacists are willing to participate in electronic prescription systems [110]. This suggests that researchers could add e-prescribing services to integrated care and could also provide spiritual comfort services with the help of robots.
At the technical level, inadequate ICT infrastructure, limited functionality and complex processes for using technology, poor compatibility between e-health tools and privacy/security issues are impediments to integrated care implementation. MARTONO et al. [111] found that poor ICT system quality and information quality reduces users' perceived usefulness and perceived ease of use. Based on technology acceptance model analysis, perceived usefulness and ease of use affect users' behavioral intentions. In addition, collaborative care between multidisciplinary teams requires the sharing of patient data, and the main challenges to data transfer are privacy and security issues. The study found that users' perceived privacy and perceived security affect their willingness to continue ICT adoption [112]. Ogal et al. [113] also identified interoperability and compatibility of ICT systems, and privacy issues as major barriers to sharing healthcare records, which can affect smooth communication and coordination of care between multidisciplinary teams and reduce stakeholder trust and user engagement. User engagement affects their perceived usefulness, perceived ease of use and behavioral intentions [114]. This suggests that researchers can design comprehensive, convenient and interoperable platforms for integrated care services based on the technical functional requirements of both the supply and demand sides of the service.
At the system level, there are still impediments to the operation of ICT-based integrated care, such as inadequate legislative frameworks, insufficient funding and uncertainty about cost-effectiveness. For example, the England has had a succession of policies in place since 2010 to encourage the integration of health and social care, but the layering of numerous policy initiatives has affected the establishment of integrated relationships and the chronic underfunding of social care has led to significant workforce challenges [115]. In addition, inadequate financial support and weak cost-effectiveness could discourage the allocation of funds to individuals, hospitals and departments, and thus fail to incentivize the integration of care [116]. The German Federal Government has launched the Healthcare Innovation Fund, which provides €200 million per year from 2020-2024 to support the development and diffusion of integrated healthcare and to stimulate relevant insurance companies to support the development of new models of integrated care [117]. Policies introduced by the US and state governments have initiated health funding to provide financial support for social care [118]. Stokes et al [119] stimulated more integrated activities by pooling health and social care funding. Four practice models in this study showed no net monetary benefit and somewhat reduced incentives for multidisciplinary team members, older adults, and their caregivers to participate in integrated care, possibly because recruiting multidisciplinary team members increases labor cost expenditures, while shortterm interventions do not improve health outcomes for frail or multiply chronically ill older adults, and early implementation of the intervention's aggressive practices may increase older adults' use of services and informal care, indirectly increasing the cost of interventions. This suggests that governments should take the lead in incentivizing multiple sources of financing to provide appropriate services based on matching supply and demand to reduce the cost of interventions and protect economic benefits.

CONCLUSION
The ICT-based integrated care model used digital communication, electronic health record, clinician and patient information systems as vehicles to form multidisciplinary teams to provide diversified services by vertical and horizontal integration of health and social care institutions, combining seven core elements of single entry point, comprehensive geriatric assessment, personalized care planning, multidisciplinary case conferences, coordinated care, case management and patient empowerment, which met the needs of both service providers and demanders to some extent. However, there is still heterogeneity in their practice effects and the team will conduct further systematic review to assess the actual effect of ICT-based implementation of integrated care through a rigorous quality evaluation of the literature and consolidation of results. Moreover, fewer included studies focused on barriers and facilitators of ICT-based implementation of integrated care, and the combined evidence may not be convincing; researchers could use qualitative research to gain insight into the current state of local practice and key elements to facilitate successful implementation of ICT-based integrated care before formal intervention.

FUNDING INFORMATION
This study was funded by the National Natural Science Foundation of China (71874162).