In this study, the patients from the department of Geriatrics, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, China, between June 2021 and December 2021 were selected as study subjects. Inclusion criteria: (i) age 60 years or older; (ii) hospitalization time more than 24h; (iii) with clear consciousness and no difficulty in communication. Exclusion criteria: (i) presence of severe cognitive impairment or psychiatric disorders, unable to communicate; (ii) history of bone fracture within 6 months, or limb movement disorders. A randomized numerical table method was used to divide the patients into intervention and control groups, with 30 cases in each group. Protocol of the study was approved by the Ethics Committee of the hospital (2021 − 0253), and each of the enrolled patients signed an informed consent form.
1.2 Measures
The control group implemented routine nursing care, including basic nursing care, disease-related knowledge education, medication guidance, rehabilitation and discharge guidance, environmental care such as prevention of falls, pressure injuries and other adverse events. Monthly telephone follow-up was conducted after discharge.
The intervention group implemented the "hospital-community-family" multidisciplinary integrated care based on conventional care. Details of the ICOPE strategy were as follows: (i) established an integrated care management team, including geriatricians, geriatric nurses, health education nurses, clinical dietitians, rehabilitators, and psychological counsellors in the hospitals; nurses from the community healthcare institutions, general practitioners, and volunteers in the community; and family primary caregivers. (ii) the group members were trained once a week before the implementation of the integrated care intervention program, including the concept of integrated care, definition of frailty, screening criteria and early intervention management, multidisciplinary collaborative integrated care model program, management of medical records, health education, and out-of-hospital follow-up visits. (iii) the geriatricians were responsible for room visits and consultations. The geriatric nurses were responsible for screening of patients on admission with comprehensive geriatric assessment, determining the treatment plan and treatment goals with the geriatricians, participating in the whole process of patients' debilitation management, and taking charge of the out-of-hospital follow-up and other extended care services. Clinical dietitians provide dietary guidance for patients and formulate personalized dietary plans. The rehabilitation therapist will formulate a personalized exercise plan according to the patient's functional status, to promote the early recovery of the patient's physical functions. Psychological counsellors routinely assess the patient's psychological state, identify potential psychological risks promptly, and work with the carers to adopt targeted psychological interventions for the patient. During the implementation of the programme, the team held a weekly multidisciplinary collaborative meeting to provide timely feedback on the patient's problems, and the team members negotiated together to solve the problems and dynamically adjust the care programme. Community medical institutions set up professional care teams under the guidance of hospitals, which are responsible for screening, two-way referral, health education and family follow-up of geriatric infirmity.
1.2.1 Interventions in hospital
On admission, a geriatric nurse completes a comprehensive assessment. A multidisciplinary collaborative integrated care strategy was initiated after admission. (i) Nutritional guidance: the recommended target amount of energy is 20∼30 kcal/kg− 1d− 1, which is calculated according to 120% of the actual body weight for low-weight elderly, and according to the ideal body weight for the obese elderly; the recommended target amount of protein intake is 1.0∼1.5g/kg− 1d− 1, of which 50% is high-quality protein, such as whey protein [11] [12]. Clinical dietitian developed a week of nutritional recipes taking into account the patient's condition and his dietary preferences, the recipe included three meals and two fruit time, the meal time was fixed. Food were prepared by stewing, boiling, steaming and stew-based, less fried, smoked or grilled. Fish, shrimp and meat into a food mince, which were easy for the elderly to chew were recommended for the patients with difficulty in swallowing. (ii) medication care training: geriatric nurses participated in medication care training for patients and caregivers. They hold out health lectures for patients or primary caregivers every week to inform the common adverse effects of drugs, medication precautions. They instructed patients to take medication correctly, do not arbitrarily reduce or stop taking medication, and told the patient any emergence of anomalies after taking the medication should be timely feedback. (iii) Exercise programme: according to the guidelines for clinical management of Asia-Pacific debility [13], a multi-component exercise intervention programme combining aerobic training, resistance training, co-ordination training, balance and flexibility training was developed by rehabilitators according to the patient's activity ability. a. 10 minutes of warm-up training was performed first, such as marching in place, head exercise, lumbar exercise, shoulder and neck encircling, and lumbar exercise. b. Resistance training was performed for 20 minutes: elastic band double-arm pulldowns for shoulder exercise, elastic band double-arm biceps curls for upper limb exercise, elastic band single-arm trombone chest thrusts for upper limb exercise, elastic band upper arms chest horizontal push for chest exercise, elastic band back pull rowing for back exercise, elastic band bilateral hip abduction for hip exercise, elastic band unilateral hip flexion for lower limb exercise, elastic band unilateral knee extension for lower limb exercise, the above movements are repeated 6 times in each group, a total of 3 sets of training, the training duration of 20 minutes. c. Aerobics for 10 minutes: brisk walking or jogging. d. Balance training 10 minutes: toe-heel stand, one-leg stand, knee lift, toe-to-heel stand. e. Stretching training 10 minutes: shoulder and foot stretch, upper back stretch, quadriceps stretch, calf muscle group stretch. Heart rate Borg and subjective exertion score were used to determine the intensity of exercise. (iv) Psychological guidance: psychological counsellors provided psychological care for patients and pay attention to their psychological and social needs. They guided the carers to accompany and strengthen the communication between patients and carers, and providing adequate professional care and psychological support.
1.2.2 Interventions in community
General practitioners in community healthcare organisations conducted regular home visits to help patients receiving medical care, assess their health and recovery process routinely, train their family carergivers on daily care.
1.2.3 Interventions in family
A daily diet and exercise diary was reported by the patient or primary carergiver to the multidisciplinary medical team and took weekly telephone followed by a geriatric nurse or a home visit by a community general practitioner.
1.3 Screening scales
1.3.1 Frailty phenotype [14] assessment scale
There are 5 indicators included in the scale: loss of body mass, fatigue, slow walking speed, low grip strength, and low physical activity. The score range was 0–5, with 0 being normal, 1–2 being prefrailty, and ≥ 3 being frailty, with higher scores indicating more severe debilitation. For the measurement of grip strength in this study, the subjects held the grip strength meter with the dominant hand with force, the body was erect, the feet were separated naturally with shoulder width, the arms were naturally lowered, and the grip was tightened with the maximum force, and the test was conducted twice, taking the maximum value. Step speed was measured using the 4-metre step speed measurement method, the subject was instructed to complete a 4-metre straight line walk at the usual step speed (with the aid), and the measurement was repeated three times, taking the minimum value of the measurement time. Assistive devices could be aided for walking.
1.3.2 Mini-Mental State Examination (MMSE)[15]
MMSE consists of 12 items to assess orientation to time and place, attention, memory, language, and visual construction. It yields a single total score ranging from 0 to 30, with lower scores denoting more impaired cognition.
1.3.3 Geriatric Depression Scale (GDS-15) [18]
The simple version of the geriatric depression scale contains 15 items, and the subjects answer with "yes" or "no". Each answer with "yes" counts for 1 point, and "no" counts for 0 points. The higher the score, the more obvious the depressive symptoms [16].
1.3.4 Perceived Social Support Scale (PSSS) [17]
The scale contains three dimensions of family support, friend support and other support, with 12 entries. Each entry is scored on a scale of 1 to 7, from strongly disagree to strongly agree, with a total score of 12 to 84, with higher scores indicating more social support for the patient.
1.3.5 WHO QOL -BREF [18]
The scale includes 4 dimensions of somatic health, psychological functioning, social relationships and environment, with 26 entries.
1.4 Methods for collecting information on evaluation indicators
The geriatric nurses collected general information about the patients through the hospital's electronic medical record information system. Patients were assessed by two geriatric nurses before and 12 weeks after the intervention and double-checked to ensure the accuracy and completeness of the data.
1.5 Statistical methods
Continuous variables were expressed as mean and standard deviation, and categorical variables were expressed as numbers and percentages (%). The characteristics of the control group and intervention group were compared using the Kruskal-Wallis test or chi-squared test. P-values < 0.05 were considered statistically significant. Data were analyzed in SPSS Statistics (version 26.0).