Service user, carer and provider perspectives on integrated care for older people with frailty, and factors perceived to facilitate and hinder implementation: A systematic review and narrative synthesis

IntroductionOlder people with frailty (OPF) can experience reduced quality of care and adverse outcomes due to poorly coordinated and fragmented care, making this patient population a key target group for integrated care. This systematic review explores service user, carer and provider perspectives on integrated care for OPF, and factors perceived to facilitate and hinder implementation, to draw out implications for policy, practice and research.MethodsSystematic review and narrative synthesis of qualitative studies identified from MEDLINE, CINAHL, PsycINFO and Social Sciences Citation Index, hand-searching of reference lists and citation tracking of included studies, and review of experts’ online profiles. Quality of included studies was appraised with The Critical Appraisal Skills Programme tool for qualitative research.ResultsEighteen studies were included in the synthesis. We identified four themes related to stakeholder perspectives on integrated care for OPF: different preferences for integrated care among service users, system and service organisation components, relational aspects of care and support, and stakeholder perceptions of outcomes. Service users and carers highlighted continuity of care with a professional they could trust, whereas providers emphasised improved coordination of care between providers in different care sectors as key strategies for integrated care. We identified three themes related to factors facilitating and hindering implementation: perceptions of the integrated care intervention and target population, service organisational factors and system level factors influencing implementation. Different stakeholder groups perceived the complexity of care needs of this patient population, difficulties with system navigation and access, and limited service user and carer involvement in care decisions as key factors hindering implementation. Providers mainly also highlighted other organisational and system factors perceived to facilitate and hinder implementation of integrated care for OPF.ConclusionsSimilarities and differences in lay and professional stakeholder perspectives on integrated care for OPF and factors perceived to facilitate and hinder implementation were evident. Findings highlight the importance of addressing organisational and system level components of integrated care and factors influencing implementation for OPF. Greater attention needs to be placed on collaboratively involving service users, carers and providers to improve the co-design and implementation of integrated care programmes for this patient population.**引言** 老年衰弱患者（Older people with frailty，OPF）因照护协调不足、服务碎片化，往往面临照护质量下降与不良预后风险，因此该人群是整合照护（integrated care）的核心目标群体。本系统综述（systematic review）旨在探讨服务使用者（service user）、照料者（carer）及服务提供者（provider）对OPF整合照护的看法，以及被认为可促进或阻碍其实施的影响因素，以期为政策制定、临床实践与相关研究提供启示。 **方法** 本研究为系统综述及质性研究（qualitative studies）叙事综合（narrative synthesis），检索数据库包括医学文献分析与检索系统（MEDLINE）、护理及联合健康文献索引（CINAHL）、心理学信息数据库（PsycINFO）及社会科学引文索引（Social Sciences Citation Index），同时辅以手工检索纳入研究的参考文献列表、引文追踪，以及专家线上资料审阅。纳入研究的质量采用质性研究关键评价技能计划（Critical Appraisal Skills Programme，CASP）评价工具进行评估。 **结果** 本综述共纳入18项研究进行叙事综合。针对OPF整合照护的利益相关方（stakeholder）视角，我们归纳出4类核心主题：服务使用者对整合照护的差异化偏好、系统与服务组织架构要素、照护与支持的关系维度，以及利益相关方对照护结局的认知。服务使用者与照料者强调可信赖的专业照护连续性（continuity of care），而服务提供者则认为，不同照护领域服务方之间的照护协调优化是实施整合照护的核心策略。针对整合照护实施的促进与阻碍因素，我们归纳出3类核心主题：对整合照护干预措施及目标人群的认知、服务组织层面因素，以及影响实施的系统层面因素。不同利益相关群体均认为，该人群照护需求的复杂性、系统导航与准入障碍，以及服务使用者及照料者参与照护决策的程度不足，是阻碍整合照护实施的核心因素。服务提供者同时还提及了其他可影响OPF整合照护实施的组织与系统层面因素。 **结论** 本研究明确了普通民众与专业利益相关方在OPF整合照护认知，以及其对整合照护实施的促进/阻碍因素认知上的异同。研究结果凸显了针对OPF整合照护的组织与系统架构要素，以及影响其实施的相关因素进行优化的重要性。未来需进一步关注多方协同参与，即服务使用者、照料者与服务提供者的共同参与，以优化该人群整合照护方案的协同设计与实施流程。