Integrated long-term care for community-dwelling frail elders

Evidence Rating  
Evidence rating: Scientifically Supported

Strategies with this rating are most likely to make a difference. These strategies have been tested in many robust studies with consistently positive results.

Health Factors  
Date last updated

Integrated long-term care (LTC) is delivered by a multidisciplinary team of professionals working collaboratively to meet the full range of patient needs. Team members plan care jointly and share patient records; in some cases, care is coordinated by a nurse care manager1. This type of care is usually delivered to elders with multiple complex needs who live in community settings1, 2. Frail elderly patients are at increased risk of adverse outcomes from conditions that could be prevented with early detection and treatment3.

What could this strategy improve?

Expected Benefits

Our evidence rating is based on the likelihood of achieving these outcomes:

  • Reduced hospital utilization

  • Improved day-to-day functioning

  • Reduced nursing home use

  • Increased caregiver satisfaction

Potential Benefits

Our evidence rating is not based on these outcomes, but these benefits may also be possible:

  • Reduced falls

  • Improved quality of life

What does the research say about effectiveness?

There is strong evidence that integrated long-term care reduces hospital utilization1, 2, 3, 4, 5, 6, nursing home use1, 2, and caregiver burdens1, 3 for community-dwelling frail elders with multiple, complex needs more than usual care. Integrated long-term care has also been shown to improve basic functioning and health1, 2.

Integrated long-term care reduces the number of emergency room visits4, 5 and decreases the length of hospital stays for frail elders6. In some circumstances, integrated care can also reduce patients’ risk of falling2 and improve quality of life5, 7.

Stable frail elders with chronic obstructive pulmonary disease (COPD) who receive integrated long-term care have lower levels of depression and lower mortality rates than patients who receive usual care5. A Switzerland-based study indicates that frail elderly patients who receive integrated care are more likely to die at home than in an institution4.

Researchers suggest that case managers8, 9, care continuity, person-centered care, needs assessment, and shared goals and values9 are key components of successful integrated long-term care.

Integrated long-term care appears to reduce the total cost of care by reducing hospitalizations and nursing home care, but program expenses can erode cost savings in some circumstances1.

How could this strategy impact health disparities? This strategy is rated no impact on disparities likely.
Implementation Examples

The federal Program for All-Inclusive Care for the Elderly (PACE) offers home care for Medicare and Medicaid enrollees eligible for nursing home care but able to safely remain at home. Examples of care covered by PACE include adult day primary care, dentistry, emergency services, home care, physical therapy, and meals10. As of 2016, there are over 100 independent PACE organizations across the U.S.11.

Implementation Resources

CMS-PACE - Centers for Medicare & Medicaid Services (CMS). Program of all-inclusive care for the elderly (PACE).

US DHHS-LTC - U.S. Department of Health and Human Services (U.S. DHHS). Find your path forward. Resources, long-term care (LTC) pathfinder, and cost information.


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1 Trivedi 2012 - Trivedi D, Goodman C, Gage H, et al. The effectiveness of inter-professional working for older people living in the community: A systematic review. Health and Social Care in the Community. 2013;21(2):113-28.

2 Beswick 2008 - Beswick AD, Rees K, Dieppe P, et al. Complex interventions to improve physical function and maintain independent living in elderly people: A systematic review and meta-analysis. Lancet. 2008;371(9614):725–35.

3 Eklund 2009 - Eklund K, Wilhelmson K. Outcomes of coordinated and integrated interventions targeting frail elderly people: A systematic review of randomised controlled trials. Health & Social Care in the Community. 2009;17(5):447–58.

4 Di Pollina 2017 - Di Pollina L, Guessous I, Petoud V, et al. Integrated care at home reduces unnecessary hospitalizations of community-dwelling frail older adults: A prospective controlled trial. BMC Geriatrics. 2017;17(1):53.

5 Hernandez 2015 - Hernández C, Alonso A, Garcia-Aymerich J, et al. Effectiveness of community-based integrated care in frail COPD patients: A randomised controlled trial. npj Primary Care Respiratory Medicine. 2015;25(1):15022.

6 Meret-Hanke 2011 - Meret-Hanke LA. Effects of the program of all-inclusive care for the elderly on hospital use. The Gerontologist. 2011;51(6):774–85.

7 Looman 2014 - Looman WM, Fabbricotti IN, Huijsman R. The short-term effects of an integrated care model for the frail elderly on health, quality of life, health care use and satisfaction with care. International Journal of Integrated Care. 2014;14(4).

8 Wodchis 2015 - Wodchis WP, Dixon A, Anderson GM, Goodwin N. Integrating care for older people with complex needs: Key insights and lessons from a seven-country cross-case analysis. International Journal of Integrated Care. 2015;15(6).

9 Threapleton 2017 - Threapleton DE, Chung RY, Wong SYS, et al. Integrated care for older populations and its implementation facilitators and barriers: A rapid scoping review. International Journal for Quality in Health Care. 2017;29(3):327-334.

10 CMS-PACE - Centers for Medicare & Medicaid Services (CMS). Program of all-inclusive care for the elderly (PACE).

11 CWF-Hostetter 2016 - Hostetter M, Klein S, McCarthy D. Aging Gracefully: The PACE Approach to Caring for Frail Elders in the Community. New York: The Commonwealth Fund (CWF); 2016.