World Health Organization · 1st edition, 2024 · 85 pages
Normative guidance on essential long-term care interventions for older adults and carers to be integrated into health and social systems under UHC.
- Issuer
- World Health Organization
- Edition
- 1st edition, 2024
- Audience
- Government officials and policy-makers responsible for planning and providing LTC services nationally or subnationally; health, LTC and insurance organisations; regulatory bodies; care managers in public, private and civil society organisations; health and social care workers; researchers; older people, carers and communities for advocacy.
- Evidence
- Consensus-based through scoping review of 305 articles (273 interventions grouped into 49 clusters), multi-stage expert consultation, and consultation with civil society organisations representing older people and carers. Core list selected by feasibility for low-resource settings, importance, acceptability and feasibility.
- Reviewed
- 23 Oct 2026 · GMJ
What this guideline says
GMJ summary
This WHO package defines a core set of long-term care (LTC) interventions for older people with significant loss of intrinsic capacity who require sustained assistance to maintain functional ability and dignity. It addresses health care needs (screening and management of cognitive decline, limited mobility, falls, malnutrition, sensory impairment, depression, polypharmacy, pain, incontinence, pressure injury, infections, oral disease), palliative care needs (physical, psychological, social and spiritual support for serious illness and end-of-life), and social care and support (assistance with ADL and IADL, participation in community life, assistive products, accessibility, and support for unpaid carers including psychosocial support and respite care).
The package emphasises person-centred integrated care delivered by multidisciplinary teams across home, community and facility settings, with care coordination, holistic assessment, individualised care planning and promotion of self-care. It recognises unpaid carers—predominantly women—as both providers and recipients of care who require their own health, training and respite support. Two facilitating factors underpin delivery: person-centred integrated care (including assessment, care planning, case management and coordination) and education and training for both carers and LTC workers.
Countries are expected to adapt the core list of 23 interventions to national context, resources and existing services, progressively building LTC systems aligned with UHC, primary health care and healthy ageing frameworks. An extended list of 8 additional interventions is provided for settings with greater capacity. Implementation requires coordinated governance across health, social care, labour and finance sectors, sustainable financing, workforce development, information systems and meaningful engagement of older people and carers in service design.
Key points
For clinicians — doses and thresholds as stated in the guideline
- Screen and assess intrinsic capacity in five domains (cognitive, locomotor, vitality, sensory, psychological) using ICOPE approach; conduct comprehensive functional assessment of ADL and IADL, social support, environment and carer burden.
- Manage cognitive decline with rehabilitation (cognitive stimulation, cognitive training, reminiscence therapy, person-tailored activities, behavioural interventions) and assistive products for cognition (memory aids, pill organisers).
- Address limited mobility with multimodal exercise programmes (strength, aerobic, balance, flexibility), protein supplements for those at risk of malnutrition, topical analgesics for pain, and functional positioning for severe limitation.
- Prevent falls through medication review and de-prescribing, management of orthostatic hypotension, balance-challenging exercises, home modification; in care homes optimise nutrition (calcium, protein, vitamin D) and avoid physical restraints.
- Provide palliative care for older people with serious or debilitating illness: assess and treat physical symptoms (pain, breathlessness, nausea, constipation), psychological distress (depression, anxiety, grief), social and spiritual needs; discuss advance care planning regularly.
- Deliver social care and support: assistance with ADL/IADL by trained personal care workers; provision of assistive products (walking aids, wheelchairs, hearing aids, glasses, continence products); interventions to reduce social isolation and promote community participation.
- Support unpaid carers through assessment of their physical, psychological and financial burden; provide psychosocial interventions (psychoeducation, counselling, support groups—peer-led or facilitated, web-based or telephone); and respite care (home respite by personal carers, short-term residential care, day care, volunteer support).
- Ensure person-centred integrated care by: conducting holistic multidimensional assessment (health, functional, social, environmental, carer needs); developing individualised goal-oriented care plans with older people and carers; appointing care coordinators to link multidisciplinary teams and services; and promoting self-care and adherence.
Overview of interventions for health care needs
Table extracted from the guideline
| Need | Assessment | Management |
|---|---|---|
| Cognitive decline | Screen and assess for mild cognitive impairment and dementia (history, physical examination, laboratory tests, imaging, clinical assessment of cognitive function and depression) | Rehabilitation for dementia: cognitive stimulation, cognitive training, reminiscence therapy, person-tailored activities, behavioural interventions, assistive products for cognition |
| Limited mobility | Screen and assess for reduced mobility (history, underlying conditions, physical examination, performance tests, nutrition assessment) | Multimodal exercise (strength, aerobic, balance, flexibility), oral protein supplements for those at risk of malnutrition, topical analgesics, weight monitoring, positioning to prevent contracture |
| Falls | Assess risk of falls (history, gait/balance, fear of falling, visual/cognitive impairment, risky behaviour, environmental risks, polypharmacy, cardiovascular problems); conduct post-fall assessment | Medication review and de-prescribing, manage orthostatic hypotension, balance-challenging and functional exercises, home modification; in care homes: optimise nutrition (calcium, protein), vitamin D, no physical restraints |
| Malnutrition | Screen and assess nutritional status (history, physical examination, diagnosis of wasting) | Oral nutritional supplementation (protein), dietary advice, weight monitoring, oral care, rehabilitation of oral muscle function, food/feeding modifications, facilitate access to groceries or community catering |
| Depressive symptoms and anxiety | Screen with standardised questionnaires; clinical assessment of depression and anxiety (low energy, fatigue, sleep problems, depressed mood, anxiety); identify associated conditions | Antidepressants, cognitive behavioural therapy, problem-solving counselling, multimodal physical exercise, mindfulness, motivation to remain mobile and socially connected; refer major depression to specialist |
Source: World Health Organization, Long-term care for older people: package for universal health coverage. Reproduced in summary form.
From the guideline
Verbatim
“LTC comprises the activities to ensure that people with or at risk of a significant ongoing loss of intrinsic capacity can maintain a level of functional ability consistent with their basic rights, fundamental freedoms and human dignity.”
Editor’s perspective
Why this matters for Georgia and the region
Prof. Giorgi Pkhakadze, MD, MPH, PhD
Editor-in-Chief, Georgian Medical Journal · Chair, Public Health Institute of Georgia · WHO consultant, health and migration
As Chair of the Public Health Institute of Georgia and former advisor on healthy ageing, I see this package as a critical roadmap for Georgia, where 15% of the population is now over 65 and informal family care—largely by women—remains the default. Our UHC programme has achieved impressive coverage for acute and communicable disease care, but we lack a formal LTC system: no standardised needs assessment, no recognised personal care worker profession, minimal home-based services outside Tbilisi, and no financial protection for social care costs. The most immediately actionable recommendation for Georgian clinicians is to begin systematic screening of intrinsic capacity in primary care using the ICOPE approach, which can be integrated into our existing chronic disease management programmes at community polyclinics and identify older adults who need coordinated LTC before crises occur. The realistic implementation challenge is governance: LTC interventions span the Ministry of Health (medical care, rehabilitation), the Ministry of Labour, Health and Social Affairs (social services, cash assistance), municipalities (day centres, home care where it exists) and the private sector (unregulated carers), with no single coordinating authority, no pooled financing and no shared data system—resolving this will require political commitment at the highest level, beyond technical guidance alone.
ORCID 0000-0001-7609-4515 · Perspective written for the GMJ Guidelines Library, 23 Oct 2026
Applicability
Georgia and the South Caucasus
Georgia’s Universal Health Coverage programme (since 2013) and ageing population (15% aged ≥65 in 2020, projected 24% by 2050) create both opportunity and urgency for integrating this LTC package. The country has strong primary health care infrastructure and experience co-locating health and social services (e.g. community polyclinics), which can serve as platforms for person-centred LTC. Key challenges include: establishing formal care coordination mechanisms across the Ministry of Health and Ministry of Labour, Health and Social Affairs; developing and regulating the personal care worker cadre (currently informal); extending the State Medical Insurance Programme to cover social care interventions (currently limited to acute and some chronic disease management); and addressing the heavy reliance on unpaid family carers—predominantly women—without formal recognition or support. National programmes should prioritise: defining eligibility criteria and assessment processes for LTC; creating a registry of LTC needs; piloting integrated care teams in urban and rural settings; establishing training and certification standards for personal care workers and care coordinators; and ensuring assistive products are included in the State procurement and reimbursement system.
Questions this guideline answers
Quick answers
Who is eligible for long-term care services under this package?
Older people (aged 60+) with significant ongoing loss of intrinsic capacity who require sustained support and assistance to maintain functional ability and perform activities of daily living (ADL) or instrumental ADL. Eligibility is determined by comprehensive person-centred assessment of health, functional status (ADL/IADL limitations), intrinsic capacity (cognitive, locomotor, vitality, sensory, psychological domains), social support and environment—not solely by age, a single disease diagnosis or social vulnerability. The assessment should be conducted by trained health or social care professionals using standardised tools.
What are the minimum components of a person-centred assessment for LTC?
A holistic multidimensional assessment must include: (i) social and environmental context (socioeconomic status, financial situation, support structure, costs of care); (ii) health conditions, diseases, risk factors for noncommunicable diseases and medications; (iii) intrinsic capacity in five domains (vitality, hearing, vision, cognition, locomotor, psychological); (iv) functional ability and need for support in basic ADL (eating, grooming, dressing, toileting, bathing, transferring) and IADL (phone use, shopping, food preparation, housekeeping, laundry, transport, medication management, finances); (v) mobility across life spaces; (vi) social relationships (loneliness, isolation risk); (vii) autonomy, independence, dignity and opportunities for lifelong learning; and (viii) social participation. For carers, assessment must cover their physical and mental health, perceived burden, financial vulnerability, skills, knowledge and training needs.
How should palliative care be integrated into long-term care for older people?
Palliative care should be provided by doctors or nurses with at least basic palliative care training (a specialist is not required for most needs) for older people with one or more serious, debilitating or life-limiting diseases (dementia, chronic obstructive pulmonary disease, cardiac failure, musculoskeletal disorders, cancer). It includes: regular comprehensive assessment of physical symptoms (pain, breathlessness, fatigue, nausea, vomiting, anorexia, constipation, delirium, insomnia); psychological, social and spiritual needs (depression, anxiety, existential distress, stigma, carer and bereavement needs); pharmacological and non-pharmacological symptom management; advance care planning discussions (preferences for place of care, place of death, life-sustaining treatment, hospital transfer); and regular review of goals of care with patient and family, especially after major changes in health status. The palliative care plan should be integrated into the overall LTC care plan, shared with all members of the multidisciplinary team and care network, and adapted as the disease trajectory and clinical condition evolve.
What support should be provided to unpaid family carers?
Carers require their own comprehensive assessment of: burden and psychological distress; financial problems due to caregiving; intensity, quality and frequency of care provision; difficulty performing care activities; safety and organisational issues; lack of skills, resources, ability or knowledge; and their own health and well-being. Based on assessment, interventions should include: (i) psychosocial support through psychoeducation, counselling, peer-led or facilitator-led support groups (face-to-face, web-based or telephone), leisure and physical activity opportunities, cognitive behavioural approaches, and connection to community support networks; (ii) respite care to provide temporary relief, such as home respite by personal carers, short-term residential care for the older person, adult day-care services, or volunteer/neighbour support for a few hours; (iii) training and coaching in providing care; (iv) assistive products to facilitate caregiving; and (v) connection to social protection schemes (paid leave, cash-for-care transfers where available). Carers' needs should be assessed separately from those of the older person and included in the integrated care plan, with regular follow-up.
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- Issuer
- World Health Organization
- Type
- Guidance (normative)
- Edition
- 1st edition, 2024
- Status
- Current
- Published
- 2024-05-09
- Languages
- English (original); translations forthcoming
- Scope
- Long-term care (health, palliative, social care and support) for older people aged 60+ with significant loss of intrinsic capacity requiring sustained assistance; includes support for unpaid carers. Applicable in all settings (home, community, facilities) and all countries regardless of income level.
- Audience
- Government officials and policy-makers responsible for planning and providing LTC services nationally or subnationally; health, LTC and insurance organisations; regulatory bodies; care managers in public, private and civil society organisations; health and social care workers; researchers; older people, carers and communities for advocacy.
- Pages
- 85
- Licence
- CC BY-NC-SA 3.0 IGO
- ISBN
- 9789240086555
- Evidence
- Consensus-based through scoping review of 305 articles (273 interventions grouped into 49 clusters), multi-stage expert consultation, and consultation with civil society organisations representing older people and carers. Core list selected by feasibility for low-resource settings, importance, acceptability and feasibility.
- Next review
- Not stated; part of ongoing United Nations Decade of Healthy Ageing (2021–2030) technical guidance series
- Record history
- Created 23 Oct 2026 · updated 23 Oct 2026 · next check Apr 2027
World Health Organization. Long-term care for older people: package for universal health coverage. Geneva: WHO; 2024. 85 p. (WHO/UHL/AHE/24.01). Licence: CC BY-NC-SA 3.0 IGO.GMJ Guidelines Library records are original summaries written by the GMJ editorial team from the issuer’s published document and reviewed by a physician. They do not replace the full guideline. The document is the copyright of its issuer and is linked, not hosted. Spotted an error or a newer edition? Tell the Guidelines Desk.
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