Models of Integrated Acute Care for Older Adult Inpatients That Incorporate Integrative Health: An Integrative Review

Introduction

The demographic shift towards an ever-older population is strongly associated with a substantial increase in multimorbidity, manifesting itself in older adults’ physical and mental decline and strains on current health-care systems providing episodic care.¹ Health-care systems often provide fragmented care via highly specialised health disciplines operating in silos.² Older adult inpatients often present with multiple chronic medical and social-care problems requiring simultaneous, coordinated interventions involving several professional disciplines and medical specialities.² Initiated by the United Nations (UN) General Assembly and led by the World Health Organization (WHO) in its WHO Global Strategy and Action Plan, the UN Decade of Healthy Ageing (2021–2030) aims to reduce health inequalities and improve the quality of life of older adult patients living at home and their families.³ Numerous action plans have been developed to promote comprehensive approaches to person-centred, integrated health and social-care that foster health-care pathways integrating hospital, community health, long-term care and specialist medical-care services into one seamless whole that strengthens the overall system’s functional capacities and abilities.^4–7

The term “integrated care” appeared at the end of the 1970s, initially in child and adolescent health and in the long-term care of older adults.⁸ Although the term was initially used in the context of community health-care, it has since been used in other care contexts, too. In the 1990s, integrated care approaches were developed as a means of improving the accessibility, continuity and quality of care for people with complex needs.^9,10 Integrated care ensures the continuum of care within and between different levels of care and institutions within health-care and long-term care systems (including at home)—it is integrated according to older adults’ needs throughout their life course.¹¹

Although the literature reports multiple definitions of integrated care, our review adopted the WHO’s:

an approach to strengthen people-centred health systems through the promotion of the comprehensive delivery of quality services across the life course, designed according to the multidimensional needs of the population and the individual and delivered by a coordinated multidisciplinary team of providers working across settings and levels of care. It should be effectively managed to ensure optimal outcomes and the appropriate use of resources based on the best available evidence, with feedback loops to continuously improve performance, tackle upstream causes of ill health, and promote well-being through intersectoral and multisectoral actions.¹²

Since 2019, national and regional strategies have encouraged better health-care coordination between institutions to reduce service fragmentation, improve overall health system performance and ensure the continuum of care.^13,14 Although, few studies have investigated integrated care initiatives within acute care hospitals, those that did highlighted their beneficial results for older adult inpatients, including shorter lengths of stay, fewer readmissions and greater satisfaction among patients and their families. Nevertheless, integrated care remains far less common in hospital care than in community care.^14,15 Following the same dynamic as integrated care, integrative health practices have become increasingly predominant across health-care systems.^16,17 Several studies have mentioned the joint use of conventional medicine and integrative health practices in acute-care settings to improve the health and well-being of older adult patients.^16,18,19 Many countries recognise the need to develop high-quality, safe and effective comprehensive, integrative health-care approaches.¹⁹ Older adults increasingly use integrative health strategies, with the University of Michigan’s Institute for Health-care Policy and Innovation estimating that two in three adults aged 50–80 were using at least one integrative health strategy to prevent or treat a health concern in 2022.²⁰ The present integrative review uses the National Center for Complementary and Integrative Health’s definition of complementary and integrative health: “a group of diverse medical and health care systems, practices, and products that are not presently considered part of conventional medicine”.¹⁸ This involves

diagnosis, treatment, and prevention that complement conventional medicine by adding to a common good, addressing a need not being addressed by conventional wisdom, or broadening the conceptual frameworks of medicine.²¹

The use of integrative health in hospitals is hampered by several barriers, such as fears about the risk of interactions between integrative health therapies and conventional treatments, especially older adult inpatients’ drug treatments,²² the lack of guidelines available to support the use of integrative health therapies,^23,24 health-care professionals’ negative perceptions or lack of knowledge,^25,26 and disparities in terms of funding, the reimbursement of care services and the sharing of responsibilities.^27,28 Although integrated care approaches incorporating integrative health seem to be promising means of improving older adult inpatients’ independence and well-being, few studies have investigated these two approaches in tandem.

Integrating Complementary and Integrative Medicine

Older adults increasingly accept and use complementary and integrative medicine (CIM).²⁹ Indeed, they have been widely used in many different cultures for centuries and include homeopathies and ancient healing traditions, such as traditional oriental medicine (eg, traditional Chinese medicine, acupuncture, shiatsu), Indian systems of health care (eg, Ayurveda, yoga), and Native American healing practices (eg, sweat lodges, talking circles).³⁰ CIM practices share the belief that well-being is a state of equilibrium between the spheres of spiritual, physical, and mental or emotional functioning. That state can be achieved by leading a balanced, healthy lifestyle ensured by proper nutrition, exercise, sleep habits, and the ability to regulate stress responses via meditation or other mind–body practices.³¹ CIM is often considered safer and more natural than conventional medicine when addressing common health conditions.^32,33 Some CIM practices fall into the category of lifestyle medicine, where individuals are empowered to make healthier choices about their diet, exercise, sleep, and stress management.^34–36 Although the terms alternative, complementary, and integrative are often used interchangeably, the National Center for Complementary and Integrative Health (NCCIH) defines them as follows: alternative medicine refers to a set of medical practices (eg, traditional, oriental, mind–body) based on insufficient evidence but used in place of conventional medicine; complementary medicine refers to a non-mainstream practice that is used together with conventional medicine;³⁷ and integrative medicine is an approach to health-care that uses conventional medicine and appropriate complementary therapies (ie, integrative medicine strategies) to care for the whole person. Integrative medicine strategies include chiropractic care, massage therapy, acupuncture, and meditation.³⁸ CIM emphasizes a holistic, patient-focused approach to health-care and well-being, targeting the whole person rather than any organ system.³⁸ The NCCIH has identified three categories of complementary and integrative approaches: (1) natural products (ie, herbal medicines, botanicals, vitamins, minerals, probiotics, and other dietary supplements); (2) mind and body practices (ie, massage therapy, meditation, yoga, acupuncture, chiropractic/osteopathic manipulation, hypnotherapy, tai chi, qigong, healing touch, and relaxation exercises); and (3) other complementary approaches (ie, indigenous healing practices, Chinese medicine, Ayurvedic medicine, and naturopathy). CIM is most frequently used for treating chronic somatic and mental health conditions, such as chronic pain syndrome, anxiety, or depression,^39–41 particularly when these conditions are not responding adequately to conventional approaches. Few studies, however, have looked specifically at the prevalence and effectiveness of using CIM for older adult inpatients hospitalized for acute geriatric or mental health disorders. The most commonly used types of CIM are acupuncture, herbal therapies, high-dose vitamins, massage therapy, relaxation techniques and hypnosis, guided imagery, mindfulness-based stress reduction, yoga, and prayer or other spiritual practices.³⁸ Although current trends suggest an increase in the use of CIM among older adults living in their own homes, less is known about how that use is considered and integrated into their care and treatment plans during hospitalization, regardless of whether that is for an acute physical (eg, heart disease, cancer, stroke, lung disease, diabetes) or mental disorder (eg, depression, anxiety). Despite the available evidence, CIM is rarely included in health-care systems’ standard treatments on any large scale, except for acupuncture and chiropractic care. In Switzerland, baseline health insurance schemes do not reimburse CIM; in other countries, it remains unaffordable for many older adults living on a limited income.⁴² This review sought to identify studies reporting the use of any CIM during older adults’ hospitalizations in geriatrics, psychogeriatrics, internal medicine, and rehabilitation units. The work also examines older adults’ use of CIM before, during, and after their hospital stays.

This integrative review’s first aim was to identify and explore publications on integrated care models that incorporated integrative health approaches in acute hospital settings for geriatric somatic and mental care. Its second aim was to identify tools for measuring maturity in the development of health-care institutions’ and systems’ ability to provide integrated care. The following questions guided our research: Which models of integrated care incorporating integrative health approaches are used in acute care hospitals for older adult inpatients and in their geriatric somatic and psychiatric wards during the transition between hospital and the community? How can a health-care institution’s or a health-care system’s level of development, maturity, or readiness to apply integrated care approaches be measured?

Methods

Design

Based on Toronto and Remington’s step-by-step Guide to Conducting an Integrative Review, we summarized existing studies using the following steps: (1) formulating a review question, (2) systematically searching the literature, (3) critically appraising the research retained, (4) analyzing and synthesizing the literature, (5) discussing new knowledge, and (6) developing a dissemination plan for the findings.⁴³

Eligibility Criteria

The review considered publications that focussed on older inpatients, whether men or women, aged 65 or more, hospitalised in geriatrics, old age psychiatry or rehabilitation units for any physical or mental disorder, and who received integrated care whether or not integrative health was used at hospital admission, during hospitalisation, or was planned at hospital discharge.

Types of Studies and Scientific Reports

We included cross-sectional, epidemiological, methodological, retrospective and prospective cohort studies, randomised, non-randomised, pragmatic, experimental, mixed-methods studies and qualitative research designs. Conference abstracts, letters to editors and book recensions were excluded.

Search Strategy

An initial search for models of integrated acute care among older inpatients incorporating integrative medicine or health services was conducted by two medical librarians (PM & JP) in September 2023 in the following bibliographic databases: Medline Ovid ALL, PubMed, Embase.com, CINAHL, APA PsycINFO Ovid, Web of Science Core Collection, ProQuest Dissertations & Theses A&I, Cochrane Library and CAMBase. No language restrictions were set. This search strategy was associated with the concepts of “integrated care”, “hospitalisation”, “old age” and “complementary therapy”. An additional search was conducted in December 2023 to more broadly explore models of integrated acute care for older inpatients while combining the fundamental concepts of “integrated care”, “hospitalisation”, “old age”, and “models”. We examined the following databases: Medline Ovid ALL, PubMed, Embase.com, CINAHL, APA PsycINFO Ovid, Web of Science Core Collection, ProQuest Dissertations & Theses A&I, and Cochrane Library, with no language restrictions. The search of relevant publication date was set on 1th Januari 1990 until June 2024. Additional French and English searches were conducted using Google Scholar. Figure 1 provides an overview of these search strategies, and Supplementary File 1 presents the search equations in detail (Supplementary File 1).

Figure 1 Summary search strategy flow diagram based on the PRISMA 2020 recommendations. Notes: Page MJ, McKenzie JE, Bossuyt PM, Boutron I, Hoffmann TC, Mulrow CD et al. The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. BMJ. 2021;372:n71.44

Studies Retrieved

Our search strategy retrieved 11,678 references after eliminating 2148 duplicates identified in the first search and 474 identified in the second. Based on screening their titles and abstracts, 80 articles from the first search and 116 articles from the second search were evaluated. Twenty articles from the first search and 12 from the second were retained for inclusion, providing 32 articles for our integrative review, including four publications with a hybrid focus on primary and acute care settings that provided information on Switzerland’s context of integrated care (Figure 1).

Study Screening and Data Extraction

Three researchers (EP, NT and HV) screened the references imported into Rayyan^® using titles and abstracts to identify studies that met the inclusion criteria. After reaching a consensus on the findings of their independent screening processes, the full-text articles of potentially relevant studies were obtained. The same researchers independently screened the full-text articles, labelling them for inclusion or exclusion. They discussed and resolved disagreements to reach a consensus about the final list of studies included, which were then managed in an EndNote™ library. The research team developed Microsoft Excel spreadsheets to tabulate data on the studies and to assess each study’s quality. The following information was extracted from each relevant study included and put into an appropriate usable form: (1) study authors, year of publication and country where the study was conducted; (2) name of the model involved; (3) study design; (4) study context, setting and sample size; (5) partners involved; (6) research objectives; and (7) principal results.

Methodological Quality

EP, NT and HV used five tools to independently assess the methodological quality of the studies retained. Relevant versions of the Newcastle–Ottawa Scale (NOS) for assessing the quality of non-randomised studies in meta-analyses were used to assess cohort and cross-sectional studies.⁴⁵ The risk of bias in randomised controlled trials was assessed using the Revised Cochrane Risk of Bias tool (RoB 2.0).⁴⁶ The Risk Of Bias In Non-randomised Studies of Interventions (ROBINS-I) assessment tool was used for quasi-experimental studies.⁴⁷ The Mixed Methods Appraisal Tool (MMAT) was used to measure the quality criteria in mixed-methods studies.⁴⁸ Finally, the JBI Critical Appraisal Tools were used to assess qualitative descriptive studies and case studies.⁴⁹ Any disagreements on quality assessments were resolved through discussion and consultation with the co-authors. However, studies were not excluded based on their quality assessments, as we wanted to provide an overview of all the available information. Quality assessments of the studies retained can be found in Supplementary File 2.

Data Analysis

A first analysis presents an overview of the studies retained, including the author(s), year, country, study design, population, health-care setting, objectives, and main results (Table 1). A second analysis includes the integrated care models in acute-care settings, with or without integrative medicine, the stakeholders/health-care professionals involved, and outcomes (Table 2). Finally, we analyzed the studies with reference to the 12 dimensions of the Scaling Integrated Care in Context (SCIROCCO) tool. The studies included were analyzed with reference to the 12 dimensions of the SCIROCCO tool and are presented in Table 3. Descriptive statistics were computed to document the overall sample size and distributions of the participants involved (patients, informal caregivers, health-care professionals and health-care services), including their sociodemographic details and professional characteristics.

Table 1 Characteristics of the Studies Retained

Table 2 Models of Integrated Care in Acute Hospitals and Community Health-Care and Those Incorporating Integrative Health

Table 3 Analyses for the Retrieved Studies Linked to the 12 SCIROCCO Dimensions Model.64

Results

Characteristics of the Studies Retrieved

The 32 studies included were conducted in the USA (n = 9), Singapore (n = 5), Switzerland (n = 4), the United Kingdom (n = 3), Canada (n = 2), Netherlands (n = 2), Spain (n = 2), New Zealand (n = 1), South Korea (n = 1), Israel (n = 1), Belgium (n = 1) and one joint publication covered the countries of the European Union (n = 1). They were published between 2012 and 2023. A diversity of study designs was used to explore the phenomenon of integrated care in the different countries’ health-care systems. These included five cohort studies, five quasi-experimental studies, four quantitative descriptive studies, four randomised controlled trials, three qualitative descriptive studies, three case studies, two descriptive studies, two mixed-methods studies, two methodological studies, one guideline report and one action-research project. The research populations were divided into three categories: 1) older adult inpatients and their families or informal caregivers; 2) health-care professionals and workers; and 3) local and regional health-care providers. The studies retained (including the validation studies) comprised 46,899 participants, including 39 physicians, 148 nurses, 695 other health-care professionals and 358 informal caregivers. Other health-care providers included community health-care workers, family physicians, pharmacists, social workers and allied health-care professionals (eg occupational therapists, physiotherapists, dieticians, care managers and complementary medicine practitioners). Table 1 describes the studies retained for this review in detail.

Dimensions Reported in the Studies on Integrated Care Models in Acute Care

Several studies have described the components of the integrated care concept.^81,82 Valentijn et al (2015) reported that the 59 key characteristics attributed to integrated care are divided into the four dimensions of the Rainbow Model of Integrated Care.⁸² Gonzalez-Ortiz et al (2018) proposed a list of 175 items classified into twelve domains. The first six domains, as proposed by the Chronic Care Model (CCM), are the health-care system, community resources and policies, self-management support, delivery system design, decision support systems, and clinical information systems. The six other domains are leadership, governance, performance monitoring, organisational culture, contextual factors and social capital.⁸¹ Although the Scaling Integrated Care in Context (SCIROCCO) tool is a model of the maturity of integrated care, it was developed to facilitate knowledge transfer about the implementation of integrated care and to measure the level of maturity in the development of identified components of integrated care providers and structures.⁶³ The studies included in this integrative review highlighted several integrated care models in acute hospitals, community health-care and integrative health. Table 2 describes the integrated care models retained for our integrative review. From this perspective, different authors and public health services have defined integrated acute care. Busetto et al (2017) defined the three critical components of integrated acute care for older adults as multidisciplinary organisations and collaborative practices, comprehensive geriatric assessments, and a specific cost reimbursement system.⁸³ Castelli et al (2023) defined six key components: the interface between primary care and hospital care, internal hospital processes, the use of information technology, funding, resources such as workloads, and professional roles and behaviours⁸⁴ (Table 2).

Models of Integrated Care Incorporating Integrative Health Services

Only two of our retained publications proposed integrated acute care models that incorporated integrative health.^65,77 The safety management model for incorporating complementary medicine (CM) services in a hospital setting employs reflexology, acupuncture, hypnosis and guided imagery. This model proposes three significant areas requiring safety management when using integrative health in a hospital environment: (1) the prevention of safety-related incidents via the selection of appropriate integrative health practices and practitioners, (2) actual adverse incidents, and (3) the prevention of their recurrence using both hospital and integrative health service safety protocols.⁶⁵ The second integrated acute care model reported is the Hospital-Based Integrative Healthcare (IH) Program, which includes aromatherapy, massage, acupuncture, acupressure, guided imagery, chiropractic therapy, reflective listening, relaxation techniques, energy work, reflexology, music therapy, art care and craniosacral therapy. The critical elements of this model are organising the care team into a triad (an IH nurse clinician, a massage therapist and an acupuncturist), providing ongoing training in IH for all care staff, and providing IH mentors for care staff and patients to facilitate the implementation of IH approaches into patients’ daily care routines. Nurses’ abilities to use holistic care models foster relationships between IH practitioners and care professionals and optimise the care environment.⁷⁷ Although integrative health therapies generate significant added value for older adult inpatients’ physical and psychological health, they only seem to be used sporadically during hospital stays^17,18,24 (Table 2).

Models of Integrated Care in Hospitals

We only identified two models among the few studies that investigated integrated models of care in acute care hospitals: the Acute Care for Elders (ACE) model^{53,61,66,76,78–80} and the Integrated General Hospital (IGH) model.⁵⁰ The ACE model uses an interdisciplinary approach, is organised in specific hospital units, and incorporates the principles of continuous improvement in quality, care safety and overall older adult inpatient assessment. The ACE model’s main objectives are to ensure care centred on the individual and involving their relatives and to provide a specialised environment adapted to the needs of older adult inpatients (eg carpeted floors, handrails, meeting areas for patients and their entourage, welcoming rooms). Furthermore, the model seeks to reduce the occurrence of undesirable events during hospitalisation (eg bedsores, urinary tract infections, use of restraint measures), to maintain and improve the older adult inpatient’s quality of life, to maintain and improve their functional status (eg activities of daily living, mobility, nutrition, mood, sleep, cognition, etc), and to plan quality transitional care for hospital discharge from the moment of admission^{53,61,66,76,78–80} (Table 2).

The Integrated General Hospital (IGH) model is a general practitioner-led care model where a principal physician is identified for every patient, and they maintain follow-up in outpatient settings. The principles guiding the IGH model include; (1) “Holistic Care”, where the model focuses on managing patients holistically rather than based on medical specialities; (2) “Single-Site Care”, where the IGH model provides both acute and post-acute care at a single site, enhancing care continuity by eliminating inter-site transfers; and (3) the “One Patient, One Care Team principle”, where the IGH model follows the principle of assigning one care team to each patient. This team proactively reviews older adults’ care arrangements and minimises unnecessary visits to specialists in other hospitals. Information technology infrastructure was identified as a key limitation, with difficult access to external partners outside the hospital who continue to care for the patient after discharge. The IGH model challenged traditional team structures and empowered staff to expand their roles and responsibilities.⁵⁰ We found no hospital-based integrated care models in advanced psychiatry. However, person-centred acute psychogeriatric care models have components similar to integrated care. For this reason, the dementia care pointers for service change,⁵⁴ the Admiral Nursing model,⁵⁹ the Lewy body dementia Admiral nursing service⁵⁵ and the Care for Acute Mentally Infirm Elders (CAMIE) model^57,67 were all considered in this review. These models highlight the importance of using a holistic approach to meet the biopsychosocial needs of the person with dementia and their relatives, of fostering a close interdisciplinary partnership with them, of providing ongoing dementia training for all nursing staff based on best practices in dementia care, and of promoting a dementia-friendly environment^{54,55,57,59,67} (Table 2).

Transitional Integrated Care Models Rooted in Hospital Settings

Transitional care models (TCMs) are designed to ensure the coordination and continuity of care when patients are transferred between different care settings or levels of care in the same institution. “Transfer” refers to the relatively short time that begins with a patient’s preparation to leave a facility and ends when the patient is admitted to the next facility.⁶⁸ TCMs are considered to be integrated care because these two concepts combine the same key elements. These include multidisciplinary collaboration, a comprehensive geriatric assessment, the promotion of and education in self-management, the implementation of health and social interventions focused on the patient and their entourage, and meeting their needs and expectations during hospitalisation, at discharge and during the patient’s more or less long-term follow-up in the community.⁶⁸

The Transitional Care Model (TCM) developed by Naylor et al (2008) is an American model developed specifically to prevent complications and strengthen care coordination before, during and after the hospital discharge of older adults with several chronic illnesses.⁸⁵ Eight other transitional integrated care models rooted in hospital settings were identified, including two American models (the Ideal Transition in Care (ITC) model⁶² and the Bridge Model of Transitional Care⁷⁵), two Asian models (the Returning Home or Re-home programme⁵¹ and the Integrated Practice Units (IPU) model⁷²) and four European models (the Integrated Care Programme (ICP) for older inpatients and outpatients,⁷¹ the Personalised Integrated Care programme for individuals with frequent hospital readmissions and multimorbidity,⁵⁶ the Netherlands’ Regional Transitional Care Programme⁷³ and the Transitional Care Bridge programme).⁷⁴ All these models share common objectives: interdisciplinary collaboration, person-centred care, the identification of older adults at risk, the promotion of care coordination and continuity, active involvement and the education of patients and their families, and the promotion of self-management.^{51,56,62,68,71–75}

Different health-care professionals are responsible for different models, including community nurses,^51,71,74 case manager nurses,⁵⁶ hospital registered nurses,⁶² advanced practice registered nurses,⁶⁸ family physicians^72,73 and social workers.⁷⁵

Two transitional integrated old age psychiatric care models rooted in hospital settings have been put forward in the domain of advanced-age psychiatry: the CARITAS Integrated Dementia Care Model⁶⁰ and the Transitional Care Model for Hospitalised Cognitively Impaired Older Adults.⁶⁹ These two models represent hospital–community care partnerships that endeavour to provide person-centred dementia care through ambulatory clinic consultations, case management, patient and caregiver engagement, and caregiver education and support, all within more or less long-term follow-up^60,69 (Table 2).

Impact and Outcomes of Integrated Care Models in Acute-Care Settings

As reported by Sumner et al, implementing integrated care models in acute-care settings can positively impact hospital admission rates, lengths of stay, and, potentially, patient satisfaction and readmission, the continuity of care, and coordinated home care.^50,62 Additionally, integrated care models can significantly reduce hospital admissions among older adult patients with chronic conditions such as heart diseases.⁵⁶ Reducing hospital admission rates and lengths of hospital stay will also save health-care systems money.⁸⁶ Shorter hospital stays is the most significant outcome of integrated care.⁵⁶ Reducing the number of days patients spend in acute hospital care is essential as prolonged stays increase the risk of hospital-acquired infections and disrupt patient flows due to a lack of beds.⁸⁷ Improving the exchange of patient information between hospitals and primary care following a hospital admission enables quicker follow-up once the patient has been discharged. This follow-up includes prevention interventions against further illnesses and, thus, readmissions to hospital.⁵² Lee et al reported that better communication between family caregivers also enabled better care coordination with the other stakeholders involved.⁵¹

Measuring Integrated Care’s Level of Maturity

Three publications reported on the construction, validation and use of the Scaling Integrated Care in Context (SCIROCCO) tool to measure the level of maturity in the development of integrated care in health-care institutions and systems.^58,63,64 The tool was developed by the European Innovation Partnership on Active and Healthy Ageing’s B3 Action Group on Integrated Care. It was designed to facilitate knowledge transfer and learning about the implementation and scaling up of integrated care across Europe’s different regions.⁶³ The SCIROCCO tool includes an online questionnaire to assess integrated care’s level of maturity, as organised across 12 domains covering various aspects related to how ready institutions are to deliver integrated care: Readiness to Change, Structure and Governance, eHealth Services, Standardisation and Simplification, Funding, Removal of Inhibitors, Population Approach, Citizen Empowerment, Evaluation Methods, Breadth of Ambition, Innovation Management and Capacity Building. Each dimension is assessed on a six-point scale with scores ranging from 0–5.⁵⁸ The tool also allows diagrams to be shared and compared with other users, facilitating consensus-building.⁶⁴ The tool has measured the maturity of integrated care systems in more than 60 regions and organisations across Europe and beyond—including Australia, New Zealand, Singapore, Canada, and the USA. It is not a specific tool for assessing acute or community health-care services.⁶⁴ Table 3 presents the SCIROCCO tool dimensions of maturation in the retrieved studies.

Methodological Quality of the Studies Retained

Three cohort studies were rated of high methodological quality (8–9 stars),^67,78,79 three were of moderate quality (6–7 stars),^53,56,58 and three were of low quality (< 6 stars on the Newcastle–Ottawa Scale)^70,75,76 (Supplementary File 2: Table S1). In the overall assessment, randomised controlled trials were rated as of some concern about their methodological risk of bias with a randomisation criterion at low risk of bias but a selection of reported results that was more of a concern^51,72,74,80 (Supplementary File 1: Table S2). The different evaluation domains used for the quasi-experimental studies mostly scored “moderate”^{60–62,66,69} (Supplementary File 1: Table S3). The two mixed-methods studies were of high methodological quality^50,68 (Supplementary File 1: Table S4), and the qualitative studies and case reports were mainly evaluated as being of moderate quality^{52,55,57,59,65,71} (Supplementary File 2: Table S5). Finally, given their design, it was not relevant to assess the methodological quality of the qualitative and methodological validation studies.^{13,54,63,64,73,77}

Discussion

This review searched for studies investigating models of integrated care designed for older adult patients in acute care settings and incorporating integrative health services. Despite the large sample of references found using our literature search strategy, few of the studies corresponded to our selection criteria involving acute health-care settings that incorporated integrative health services. The public health concept of integrated care has mainly been investigated in the field of primary care.^88,89 Little research has been conducted in acute-care settings that provide integrated care, coordinate that care and collaborate with multiple stakeholders, including integrative health services.

Despite numerous investigations and implementation studies that have demonstrated the effectiveness and efficiency of integrated primary health-care models, many acute-care programmes continue to use disease-oriented approaches to care provision in hospitals.^12,90 There has recently been more significant interest in how integrated care should be people-centred, embracing older adult patients as partners in their own care and ensuring that services are well coordinated around their needs.^12,91,92 Those studies reported that integrated care strategies provide better outcomes thanks to the collaboration and coordination between acute, preventative and community health-care actors.^6,88,93

Surprisingly, models of acute integrated care that incorporate integrative health services remain under-investigated despite previous research in primary care demonstrating their efficiency and effectiveness.^94–96 However, many studies have been conducted to assess the effectiveness of integrative health services for older adults, such as Tai Chi⁶⁰ and acupuncture,⁹⁷ although those studies were not exhaustive.

Vellas (2023) emphasised the importance of the early detection of older adults’ intrinsic abilities and the need to deepen our understanding of the biology of advanced age and age-related diseases in order to maintain their function.⁹⁸ Acute-care hospitals should take on a more central, regional role in the implementation of integrated care by coordinating out-of-hospital health-care service providers to ensure safe care management for patients facing higher levels of risk in the community. This could enable older adult patients to remain independent in their homes for longer or be discharged earlier during their recovery. This is all the more important for very frail patients for whom interventions must occur before it is too late for them to regain their independence. By strengthening their interface with community-based support, hospitals could help manage the health-care system’s demands and improve patient flows, benefiting both patients and hospitals as independent entities.^99,100

Integrated models of care could become essential parts of the solution to health-care systems’ growing financial challenges.¹⁰¹ Primary and acute integrated care models could help respond to the significant shift in global demographics that has seen age-related and long-term chronic conditions replace infectious diseases as the most significant challenges facing national health-care and social-care systems.^94,102 These changes mean that the economic burden of chronic illness may reach almost three-quarters of all health expenditures.^103,104 The future of health-care systems, especially in acute-care settings, will be fashioned by the need to optimise the health-care of ageing populations. Current approaches to care focusing on curative, specialist-led, hospital-based services must be more cohesive and require updating.¹⁰⁵ Integrated care in acute-care settings that incorporate integrative health services could be considered a means to promote the transformative health-care objectives of improving patients’ experiences, health outcomes and clinician well-being while lowering costs and ensuring health equity.¹⁰⁶ The use of integrative health in acute hospitals is a new paradigm with unknown parameters, including fears of the risk of interactions between integrative health therapies and conventional treatments, especially drug treatments for older adult inpatients,²² a lack of guidelines available to support the use of integrative health therapies,^23,24 negative perceptions or a lack of knowledge on the part of many health-care professionals,^25,26 and differences in terms of funding, reimbursements for the health services provided and the sharing of responsibilities.^27,28 Integrated care models in acute care should go beyond these barriers and beyond the traditional boundaries set for health-care and social-care systems. Indeed, they should embrace the social determinants of ill health by bringing together a more comprehensive range of resources, including integrative health services, to promote public health, prevent ill health and ensure older adult patients’ well-being.¹²

Two of the studies in this review investigated the impact of the primary care Integrated Care for Older PEople (ICOPE) model, which is based on three key elements: person-centred assessments (evaluating the older adult’s intrinsic abilities), integrated care (considering the older adult’s physical, mental, social, geographical and personal environment), and personalised care plans (implementing interventions based on each older adult’s specific needs).^58,63

Finally, monitoring the development of an integrated care model’s level of maturity within particular health-care systems should be encouraged. The European Union’s SCIROCCO initiative seems well suited to helping introduce integrated care into both acute-care and community health-care settings.⁶³ Further research involving the SCIROCCO model should be conducted to optimally adapt this tool for different health-care providers, contexts or systems.

Limitations

This integrative review has some relevant limitations. Firstly, despite a thorough literature search using Toronto and Remington’s step-by-step Guide to Conducting an Integrative Review,⁴³ our review may have missed some studies that met all the selection criteria due to study search errors or the investigators’ mistakes. Secondly, there may have been some biases in the investigators’ reporting of the findings from the selected studies. Thirdly, the heterogeneity in the studies retained—whether in terms of their conceptualisation of integrated care, differences between the health-care systems, countries and populations studied, or between methods of data collection, measurement and analysis—may have made comparisons between the models more difficult and led to a lack of consistency.

Nevertheless, our integrative review also has several strengths. On average, the studies included in it were of good methodological quality, thus ensuring the reliability and validity of its synthesised findings. Furthermore, having identified many studies with different designs, from various countries and in a variety of contexts of care, including grey literature, we were able to explore our research question in great depth.

Conclusions

This integrative review investigated integrated care models for older inpatients that incorporated integrative health care. It provides valuable information to nurses, general practitioners, policymakers, and other stakeholders in the integrated care of older adult inpatients in acute-care settings. Despite our exhaustive search of the existing literature, there appear to be few integrated care models relevant to acute-care hospital settings that incorporate integrative health approaches. Implementing integrated care models in acute-care hospital settings is still embryonic, and more research should be conducted to increase the relevance of these holistic approaches. Additionally, the validated (if slightly European-focused) SCIROCCO tool to assess the development of integrated care’s level of maturity in a particular health context could be instrumental in guiding the introduction and follow-up of integrative care in closer coordination with other health-care institutions and professionals, simplifying processes shared with other health-care providers, community-based services and social care. Based on the outcomes of the studies retrieved, the principal beneficial effects reported were substantially fewer readmissions and shorter hospital stays. Integrated care models, with or without integrative care, should apply a collaborative approach involving patients, informal and formal health-care professionals, and the broader health-care system. Health-care professionals should be better informed and trained about implementing integrated care models incorporating integrative health services and the benefits these bring.