C.H.K. Ma1, D.Q.L. Chua2, L. Tay3, E.W.C. Teo2, W.C. Ng4, A.Y.M. Leung5
1. Gerontology Programme, S R Nathan School of Human Development, Singapore University Of Social Sciences, Singapore ORCID: https://orcid.org/0000-0002-9420-0112; 2. Gerontology Programme, S R Nathan School of Human Development, Singapore University of Social Sciences, Singapore; 3. Sengkang General Hospital, Singapore; 4. NWC Longevity Practice, Singapore; 5. School of Nursing, The Hong Kong Polytechnic University, Hong Kong SAR, China; WHO Collaborating Centre for Community Health Services (WHOCC), The Hong Kong Polytechnic University, Hong Kong SAR, China; Research Institute for Smart Ageing (RISA), The Hong Kong Polytechnic University, Hong Kong SAR, China; ORCID: https://orcid.org/0000-0002-9836-1925
Corresponding Author: Carol Hok Ka Ma, Gerontology Programme, S R Nathan School of Human Development, Singapore University Of Social Sciences, Singapore, carolmahk@suss.edu.sg
J Frailty Aging 2024;in press
Published online August 7, 2024, http://dx.doi.org/10.14283/jfa.2024.59
Abstract
BACKGROUND: The World Health Organization (WHO) introduced the Integrated Care for Older People (ICOPE) approach to assist communities in evaluating the intrinsic capacities of older adults and proposing strategies to prevent, mitigate, or reverse declines. This study represents the inaugural attempt to assess intrinsic capacities among older adults in Singapore, aligning with the nation’s Healthier Singapore (Healthier SG) initiative aimed at enhancing quality of life.
OBJECTIVES: This study aims to investigate the feasibility of implementing Step 1 screening of the ICOPE framework, which assesses cognition, locomotion, vitality, psychological state, visual and auditory functions, within the Singapore context.
DESIGN, SETTING, AND PARTICIPANTS: Using a mixed-method approach, this cross-sectional study established a baseline understanding of the levels of intrinsic capacity in 367 community-dwelling older adults in Singapore (mean age 71.8 years), elucidated the experiences of administering the ICOPE Step 1 screening tool and the formulation of personalized care plans from the perspective of 25 assessors.
MEASUREMENTS: Participants completed ICOPE Step 1 screening, providing basic demographic and health profiles, while assessors engaged in focus group discussions.
RESULTS: Among older participants, 284 exhibited signs of decline in intrinsic capacity. The primary areas of decline were visual impairment (42.0%), hearing loss (33.5%), and cognitive deterioration (31.3%), followed by limited mobility (24.3%), malnutrition (16.1%), and depressive symptoms (16.1%). Assessors found the ICOPE screening tool user-friendly and appreciated its person-centred approach, noting its integration with care plans, which many other tools lacked. They were confident in Singapore’s capacity to adopt the ICOPE approach, citing existing practices in assessing intrinsic capacity domains and integrated care models.
CONCLUSION: Critical steps for successful implementation of the ICOPE framework include follow-up interventions like self-management strategies for declining intrinsic capacity, diagnostic assessments, and routine monitoring. Coordination between healthcare clusters and community care networks is essential for its success.
Key words: Integrated Care for Older People (ICOPE), Person-centred Care, Integrated Care.
Introduction
The World Health Organization (WHO) published the Integrated Care for Older People (ICOPE) framework to guide the assessing and promotion of intrinsic capacity (IC) of older adults for healthy ageing (1, 2). ICOPE is a community-based approach towards person-centred health and social care to optimize the functional ability of older people. IC encompasses both the physical and mental capabilities of the person, including locomotion, cognition, psychological well-being, , hearing and visual capacity, and vitality (1, 2).
Previous studies had shed light on the significance of IC among older adults across various countries (2-6). For instance, diminished IC may hinder self-care abilities, increase dependency, hospitalization rates, and mortality among older adults. However, further research incorporating the ICOPE framework within diverse contexts and healthcare systems is necessary. This research should encompass screening, care planning, and referrals to establish a comprehensive care pathway. Such a care pathway would ensure that older adults experiencing a decline in IC receive appropriate professional care, while those without decline or at risk of decline receive guidance to enhance their IC at home.
Significance and Rationale
Singapore is a super-aged society due to increased life expectancy and declining birth rates. In 2021, its life expectancy was among the highest globally and the fertility rate was one of the lowest in the world. It is expected that by 2050, the proportion of residents aged 65 years and over will increase to a third, up from 16% in 2021 (7).
Older adults are more likely to develop chronic diseases and become care dependent as they age (8). Age-related declines in hearing, vision, and mobility, which are early indicators of functional capacity loss, as well as conditions such as dementia, heart disease, stroke, and diabetes are the main causes of disability and mortality in older adults aged 60 years and over (8-10). To address the ageing challenges, the Ministry of Health (MOH) unveiled Healthier Singapore (Healthier SG), a strategy to outline a major transformation of the healthcare sector in 2022 and the Age Well Singapore (Age Well SG) programme, a strategy to promote preventive health in 2023. Through these policies, MOH prioritizes upstream efforts to promote early detection and preventive care. As part of the Healthier SG strategy, every resident has their own family physician to discuss their health goals. This may involve implementing preventive care measures, addressing risk factors proactively, and devising strategies to achieve health goals and delay the onset of diseases through personalized care plans. At the community level, Age Well SG aims to support older adults to age well in their homes and communities. Additionally, community partnerships will be leveraged to establish an integrated health and social ecosystem, aiding residents in maintaining health and wellness within the community. For example, agencies such as the Health Promotion Board (HPB), Agency for Integrated Care (AIC), People’s Association (PA), SportSG, National Parks Board, regional health clusters, as well as community partners collaborate to design healthy activities, conduct early functioning screenings and design care pathways for older adults (11).
The timing is opportune for testing the feasibility of implementing the WHO ICOPE framework in Singapore. Its holistic and person-centered approach to prevention, empowering individuals to manage their health, resonates well with the national strategy.
ICOPE procedure
Assessors training
A three-day workshop was arranged for 42 volunteers to train them as ICOPE assessors, enabling them to conduct ICOPE Step 1 screenings and develop care plans for each older adult based on the ICOPE framework. Lectures, role-plays, case studies, and hands-on practice were provided to enhance understanding of the WHO ICOPE rationales and the various steps of the assessment and care pathway.
In the last session of the workshop, these volunteers were evaluated individually on their knowledge and skills mastery. Regular online meetings, onsite observation and emails were made between the project team and the coordinators of the community centres. The centre staff disseminated the study information through phone calls and word of mouth in the community and arranged individual appointments with potential participants. The assessors explained the study, collected written informed consent, and conducted screening and care plan discussion with the participants.
Screening participants for IC impairment
Following the WHO ICOPE guidelines, the ICOPE Step 1 screening tool comprising nine items was utilized to identify signs of impairment in six conditions associated with IC among older adults in Singapore: cognitive impairment, limited mobility, malnutrition, visual impairment, hearing loss and depressive symptoms. Subsequently, assessors collaborated with the participants to establish personal goals and brief action plans based on the ICOPE handbook and local support services. A goal-driven action plan booklet was developed and provided to participants as a reminder of their health goals post-assessment. For example, participants with cognitive impairment received tips for enhancing cognitive health (e.g., reading, exercise, social activities), while those with low scores in social engagement were aided in formulating action plans to engage in beneficial activities (e.g., weekly afternoon tea with family). Assessors referred older adults with identified IC impairments necessitating further diagnostic assessment to the centre staff for appropriate follow-up as needed.
To maintain data quality, briefing and debriefing sessions were conducted for each team of assessors comprising two to three members before and after their sessions at the community centres. The entire procedure for each older adult took approximately 30 to 40 minutes, with 15 to 20 minutes allocated for the assessment and the remaining time dedicated to discussing individual care plans. Assessors participating in the project received certificates in recognition of their contributions to community health.
Methods
Study design and participants
This study employed a mixed methods approach to assess the levels of IC in older adults using the WHO ICOPE framework in Singapore. It also examined the experiences of assessors administering the ICOPE Step 1 screening tool and explored the feasibility of implementing downstream components of ICOPE, such as developing personalized care plans and establishing care pathways, for older adults exhibiting signs of IC decline.
A convenience sample of older adults was recruited between November 2022 and January 2023 through community care organizations, community events and centre activities. Eligible participants were aged 60 years and above, living independently at home, and requiring no or some support with self-care (feeding, bathing, dressing, toileting). Participants with acute cardiovascular diseases, acute infection, organ dysfunction, dementia, acute mental illness, nearly total-dependent or total-dependent in self-care, and inability to communicate in English or Chinese were excluded.
Measurements
Participants’ demographic and health profiles were collected, including age, gender, education level, marital status, living conditions, smoking and drinking behaviour, and medical history (comorbidities). Medical history was reviewed using the Charlson Comorbidities Index (CCI), which is the summation of the assigned weights of 17 main comorbid conditions that participants reported (12,13). The CCI was chosen for its advantage of capturing various combinations and severity of illnesses (14). However, because the CCI lacks risk factors, an item to check for the presence of hypertension was added since it is the most assessed risk factor in multi-morbidity (15).
Six domains of IC were assessed according to the WHO ICOPE guidelines: cognitive decline, limited mobility, malnutrition, visual impairment, hearing loss, and depressive symptom. Additionally, participants were also evaluated on their awareness of available resources for addressing IC issues and their familiarity with care services for older persons within the community.
Data analysis
Descriptive statistics (presented as frequencies and percentages) were used to summarize the IC of older adults and to identify the domains which showed signs of decline. Chi-square tests of independence and Bonferroni post-hoc tests were used to identify relationships between categorical variables. All statistical analyses were performed using IBM SPSS Statistics version 29, and a p-value of < 0.05 was considered significant.
Transcripts were analysed through inductive thematic analysis. The research team read the transcripts iteratively to understand the FGDs as a whole before openly coding the statements. Conceptually related codes were grouped into subthemes and structures and patterns were identified to develop themes. Microsoft Excel was used for qualitative data management.
Findings: Quantitative & Qualitative Results
Demographic characteristics of the participants
Assessors distributed study details and arranged individual appointments with a total of 391 participants. Information from 367 participants underwent analysis following the exclusion of individuals with incomplete data. Of these, the percentage of participants aged 60 to 69 years, 70 to 79 years, and 80 years or above were 43%, 41%, and 16%, respectively. Most of the participants were female (n=276, 75.2%), retired (n=240, 65.4%), with primary or secondary education background (67.3%), and co-resided with family (n=245, 66.8%). Over half (54%) of the participants were married, and an additional 23% were widowed. The majority of participants were never drinking (77.9%) or smoking (88.3%), with an additional 8.2% and 5.4% quitted, respectively.
Only a minority of participants (n=113, 30.8%) reported no pre-defined comorbid conditions in the CCI in the study. However, 39% (n=143) reported having one of the included comorbidities, while 30.2% indicated having two or more. Hypertension emerged as the most prevalent chronic condition, with 154 (42%) participants reporting it. Approximately a quarter of participants had diabetes (n = 88, 24%), while smaller proportions reported disorders of connective tissues (n = 28, 7.6%), malignant tumors (n = 26, 7.1%), and kidney diseases (n = 12, 3.3%). High cholesterol was reported by 52 (14.2%) participants. Table 1 summarizes the characteristics of the participants with or without IC decline.
IC of the participants
Using the ICOPE Step 1 screening tool for the initial assessment, 284 participants (77.4%) were found to have impairment in any of the six domains in IC. As shown in Table 2, the top three IC impairments among participants were visual impairment (42%), hearing loss (33.5%), and cognitive decline (31.3%), followed by limited mobility (24.3%), malnutrition (16.1%) and depressive symptoms (16.1%). The findings from the study also indicated that 22.6% of participants did not know any care services for older persons in the community, and another 8.2% did not know where they could go if any problems occurred.
Declines in IC across various age brackets were examined. Findings revealed that participants aged above 80 exhibited a greater decline in IC compared to other age groups. For example, the prevalence of cognitive decline among participants aged 80 and above was 57.6%, significantly surpassing that of individuals aged between 70 and 79 years (33.8%) and between 60 and 69 years (19.1%). Similar patterns were observed in the remaining five domains of IC, such as visual impairment, hearing loss, limited mobility, malnutrition and depressive symptoms (Table 2).
In addition, age, education level, employment status, and alcohol consumption were significantly associated with IC decline. Comparisons of IC decline by pairs of age group categories revealed a significant difference between IC decline among participants aged between 60 and 69 years (adjusted residual, z = -3.40 < -1.96) and those aged 80 years and above (adjusted residual, z = 2.15 > 1.96). Significant difference between IC decline among retirees (adjusted residual, z = 2.43 > 1.96) and participants on full-time employment (adjusted residual, z = -4.12 < -1.96) was also observed when comparisons of IC decline by pairs of employment status categories were performed. However, comparisons of IC decline by pairs of education level categories and alcohol consumption categories found no significant differences, suggesting that there was insufficient evidence to conclude that IC decline was dependent on participants’ education level and whether they consumed alcohol.
Singapore’s capability in implementing downstream components of ICOPE
A total of 25 assessors participated in the focus group discussions. They possessed expertise in implementation of ICOPE Step 1 screening within the community. In terms of the feasibility of ICOPE implementation in Singapore, they discussed both enablers and barriers as detailed below.
Enabler 1: Prior IC screenings have been successfully conducted within Integrated Health and Care Systems, paving the way for ICOPE implementation
Assessors agreed that Singapore could implement Steps 2 through 5 of the ICOPE framework well since the assessment of IC domains has already been applied in practice:
“The questions that ICOPE asked, as well as the tests done, I believe, are not new to the older adults. I suppose they have been asked in numerous different scenarios, some of them from the community angle like Community Screening Tool (CST) and even functional screening initiatives to identify age-related decline in older adults’ vision and hearing, others when they visit a doctor.” (A1)
They added that Singapore already has in place integrated care models and health system infrastructures that are similar to the downstream components of the ICOPE framework. Communities of Care (CoC) is one of the local networks that bring together agencies and partners to coordinate care and support older adults to age-in-place. Services including but not limited to chronic disease screening, frailty screening, functional screening, chronic disease management, and community nursing are offered in these CoCs to help residents stay healthy and live well (16, 17). Moreover, the Regional Health System (RHS) was established to reorganize the public healthcare system into three integrated clusters to better fulfil the future healthcare needs of Singaporeans. Each healthcare cluster brings together healthcare institutions, community partners, and social service providers to develop and execute initiatives that advance population health, encourage preventative health, and enhance overall well-being (18). Assessors agreed that both CoCs and the RHS provide a centralized system for coordinated efforts in the assessment and management of IC decline, referral to specialized care, and involving communities to support the care of older adults.
Enabler 2: ICOPE Step 1 screening process is straightforward to conduct
Assessors also expressed strong support and enthusiasm for ICOPE Step 1 screening, indicating potential feasibility in implementing Steps 2 through 5 of the ICOPE framework. They found the ICOPE Step 1 screening tool easy to use and tailored for health assessment.
“This ICOPE assessment is very short compared to the BPS Risk Screener which I am using (at the centre I work), so it was actually easy for me to administer it. In fact, the older adults were very surprised that the assessment was so quick because they were so used to long surveys (from our centre).”(A2)
“The tool is quite compact in a sense… does not drag on but very specific so it was easy to administer.” (A3)
Enabler 3: ICOPE prioritizes individualized care and empowerment of older adults through personalized care plans
Assessors also valued ICOPE for its person-centred approach, emphasizing empowerment through personalized care plans – a feature lacking in many existing assessment tools. They saw ICOPE as an opportunity to empower and engage older adults in their own health and care.
“What makes the ICOPE person-centred is the development of the care plan. It is unique to the individual as you realize what Person A can do may be something Person B cannot do from a conversation (with the older adult).” (A4)
“The whole awareness piece is interesting. The older adults were happy to have been assessed as it gave them an idea of where they were at (in terms of their IC). It got them engaged to kickstart the process of taking charge of their health, which could be as simple as seeking out more information.” (A5)
Barrier 1: Assessors may lack the necessary competency to grasp local support services and carry out assessments from Steps 2 to Step 5 of the ICOPE framework, necessitating more training
Assessors expressed concerns about their ability to comprehend local resources and execute assessments beyond Step 1 of the ICOPE framework. They emphasized the importance of possessing comprehensive knowledge of community health and care services and emphasized the need for more extensive training to effectively conduct follow-up assessments.
“It was difficult for me to refer them (older adults who are residents at Whampoa) to health and care services in the community as I had no knowledge of the specific services available in Whampoa. Having that knowledge would have been extremely helpful.” (A6)
“Currently, I see the assessor at Step 1 and Step 2 as two different individuals as I do not feel competent to conduct a person-centred assessment yet. However, if training is robust and the assessor has adequate knowledge of available health and care services in the community to make referrals, then I believe it would address the human resource constraints.” (A7)
Certainly, collaboration among stakeholders such as caregivers, older adults, and health and social care professionals is essential for improving the referral system.
Barrier 2: Securing buy-in from various stakeholders, especially the relevant ministries and central coordinating agencies is crucial
Establishing a shared understanding of ICOPE’s value in aiding older adults to alter their IC trajectories and delay decline is essential. However, obtaining buy-in from diverse stakeholders could pose potential barriers to the prospective implementation of downstream ICOPE components.
“We need a formal body to adopt it (ICOPE) – GPs (general practitioners), AIC, MOH – so that the general public knows that everybody is going towards one direction. Otherwise, it will still be fragmented.” (A8)
Barrier 3: Sharing data presents a challenge
Assessors identified a significant challenge related to sharing data among various care teams while adhering to data protection standards.
“We may think that we do not know much about the older adult, when in fact, we probably have a lot of data already given the large number of assessment tools currently available, but they just did not come to us at one place. If we were to roll out ICOPE, we need to ensure that the information flows from the individual or community level to the primary care level and if needed, to the secondary care level, so that there is continuity. How should partners coordinate and share the data? Otherwise ICOPE will just be another screening tool without any direct benefits to the older adult.”(A9)
Barrier 4: Creating a conductive environment for conducting the ICOPE Step 1 screening is essential
Assessors noted that the varying settings of the community centres could make it challenging to screen certain domains effectively, in particular, the whisper test in assessing auditory function.
“I find it challenging to assess (the) hearing (domain)… especially when there are two assessors in the same room, making it difficult to conduct the assessment.” (A10)
“The accuracy of the hearing assessment may be affected by the environment. If it’s noisy, it’s hard to determine how reliable the results are.” (A11)
“Assessing (the) hearing (domain) was a bit challenging. The distance and volume needed to be just right, and often participants would ask for repetitions, saying “mhmmm, huh, mhmmm huh?”” (A12)
Exploring opportunities in establishing a care pathway
Expanding upon the WHO’s proposed framework, assessors have underscored the significance of follow-up procedures following the development of care plans, ensuring older adults can derive benefits from the assessment. This may entail collaborating with the community nursing team to offer ongoing support to both older adults and their families.
Furthermore, assessors have emphasized the importance of conducting comprehensive assessments (Step 2 to 5) to identify conditions associated with declines in IC, followed by appropriate follow-up procedures. Should such conditions be identified, prompt referral of older adults for further investigations is advocated to facilitate timely diagnosis and integrated management. Given the holistic perspective of the ICOPE approach, the subsequent step involves evaluating and addressing the social and physical environments of each older adult, potentially requiring additional referrals.
These findings are pivotal in the review and enhancement of personalized care plans for each older adult. To strengthen support at the community or primary care levels, community engagement and caregiver support are integral components. Additionally, assessors have advocated for periodic reassessments over time to monitor the effectiveness of the care plans.
Discussion
Importance of community care support to address IC impairment in Singapore
The study findings primarily focus on the ICOPE Step 1 screen, revealing the pressing need for community-level support for older adults due to the high prevalence of IC impairment in Singapore. Alarmingly, 77.4% of older adults in this study were found to have impairment in at least one IC domain, underscoring the need for additional assessment and care planning. Of particular concern are older adults in advanced age (above 80), those with one or multiple comorbidities, or retirees, as they are more likely to exhibit impairment across multiple IC domains.
Consistent with previous cross-sectional studies among Asian older adults, this study showed a high prevalence of IC decline. For instance, in Beijing, China, 69.1% of healthy inpatients aged 50 and older exhibited at least one IC decline based solely on the ICOPE screening tool (6). Similarly, a study in Hong Kong identified IC impairment in 72.7% of older adults who required no or some support with self-care from Step 1 screening (4). Furthermore, longitudinal observational studies on older adults have revealed a progressive increase in the prevalence of IC decline over time (19), placing individuals at heightened risks of polypharmacy, incontinence, poorer self-rated health, and dependencies on instrumental activities of daily living (3). These findings collectively underscore the critical importance of addressing IC decline in old age and the urgent need to establish a care pathway for further referral.
Simple Step 1 screen with clinical implication
This study focused solely on Step 1 assessment, which carries clinical implications for the follow-up and further assessment by community care teams. The simplicity of the nine-item ICOPE screening tool makes it an ideal, resource-saving assessment tool. It can be administered by non-professionals who have received adequate training, addressing the labor shortage in aging services (20).
Furthermore, its ease of use suggests broad applicability in community settings, with significant clinical implications, particularly in identifying older adults experiencing declines in IC. Currently, many assessments used in Singapore are relatively lengthy and not well integrated into older adults’ care plans.
Importantly, the ICOPE Step 1 screening accompanied by a care plan, emphasizes empowerment and adopts a person-centred approach, often lacking in existing assessment tools. This approach not only enhances the effectiveness of care planning but also promotes a sense of agency and dignity among older adults.
Holistic care pathways and community involvement: ensuring effective interventions
As noted, one limitation of the current study is the lack of comprehensive assessment from Step 2 to Step 5. However, it is recommended that subsequent comprehensive assessments be conducted in conjunction with a well-defined care pathway. These assessments seek to ascertain whether older adults can manage independently at home or require additional support from health and care professionals for diagnosis and treatment. Follow-up measures, such as self-management of IC declines, diagnostic assessments, and routine monitoring, are identified as crucial steps of the care pathway.
Communities must also play a role in implementing effective interventions to maximize IC, as many factors influencing IC, such as health-related behaviours and the presence of diseases, are modifiable. For example, Active Ageing Centres (AACs) could explore the development of multimodal exercise programs encompassing strength, aerobic, balance, and flexibility training for older adults showing signs of IC decline, particularly in domains like cognitive and locomotor capacity (1). Additionally, they could establish peer learning initiatives on health facilitation led by trained volunteers using evidence-based curricula.
Staff and experienced volunteers from AACs can oversee Step 1 screening and monitor IC decline among older adults, while the community nursing team from the RHS and even general practitioners can handle Steps 2 to 5. They can collaborate with AACs to co-develop programs and activities aimed at maintaining or reversing IC decline. To ensure the sustainability and scalability of ICOPE, implementing a standardized accreditation system for training could be considered (2).
Incorporating ICOPE into existing healthcare systems
Additionally, the ICOPE screening tool appears to be suitable for triaging and informing the most effective order to meet the health and social care needs of older adults. These IC assessments could potentially be integrated into existing screening tools, such as the Community Screening Tool (CST) built on the ‘Assessment Urgency Algorithm’ of InterRAI, which is currently utilized at the community level to identify risks and/or needs of older adults.
The Frailty Strategy Policy Report, published by the MOH Frailty Policy Workgroup (21), recommends incorporating ICOPE into secondary screening of older adults identified as frail based on the Clinical Frailty Scale (CFS) (i.e., CFS score between 4 and 5). Older adults with CFS scores of 4 to 5, displaying decline in IC detected from ICOPE Step 1 screening, as well as those with CFS scores of 6 or above, should undergo follow-up assessments, for example Comprehensive Geriatric Assessment (CGA) in polyclinics, geriatric service hubs, and hospitals.
Indeed, there should be further exploration of integrating ICOPE Step 1 screening into primary screening and even the CST. ICOPE Step 1 screen serves as an initial screening tool designed to empower older adults to maintain their health and well-being. Having too many disparate assessment tools may inconvenience older adults and discourage them from undergoing health assessments and receiving health education.
These findings underscore the importance of prioritizing IC in old age and the urgent need for establishing care pathways for appropriate referral. Additionally, they emphasize the importance of educating older adults and their family members about these impairments through education to enhance individuals’ self-management skills and promote a shared understanding of healthy aging concepts.
Furthermore, the healthcare system should implement targeted interventions facilitated by interdisciplinary health and social teams to enhance the self-care capacity of older adults. By adopting a collaborative framework involving various healthcare professionals, social workers, volunteers, older adults themselves, and their family members, optimal health outcomes and an improved quality of life among older adults can be achieved.
Conclusion
The high level of IC decline in older adults identified through Step 1 screening alone necessitates IC assessment at the community level to promote early detection and interventions to either maintain or prevent further declines. The ICOPE screening tool also shows promise for large-scale usage. Individuals showing signs of IC decline should undergo subsequent in-depth assessments to determine if they can manage independently (or with assistance) at home, or if they require medical attention. To provide diagnostic assessments and support self-management of IC declines in older adults, a care pathway involving health and care professionals, family members, and communities should be developed. As Singapore transitions to a population health approach, focusing on wider determinants of health, empowering individuals, and strengthening communities, the ICOPE framework will be valuable in informing how aspects of the proposed care pathway can support the Healthier SG initiative.
Ethical Standards: The ethical approval including participants’ approach and recruitment were granted by the Human Subjects Ethics Sub-committee of The Hong Kong Polytechnic University, Hong Kong (reference number: HSEARS20221007004). We confirm that all methods were performed in accordance with the Declaration of Helsinki and the relevant guidelines and regulations proved by the Human Subjects Ethics Sub-committee by including an information sheet and consent to all participants. Written informed consent was obtained from all participants prior to data collection. Participants have the right to withdraw at any time during the project, and there is no impact on the services they receive in the Community Centres.
Conflicts of Interest: No conflict of interests of this article.
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