Portfolio: Evidence-based Programs for a Person-centered, Integrated Care for Older People at the Primary Health-care Level

What this guideline says

GMJ summary

This PAHO portfolio presents evidence-based programmes designed to improve or maintain intrinsic capacity in older adults at the primary health-care level. It aligns with WHO’s Integrated Care for Older People (ICOPE) framework and the Decade of Healthy Aging (2021–2030), supporting the shift from disease-focused to capacity-focused care. The document offers implementation guidance for programmes across five domains: self-management for chronic conditions, locomotor capacity and falls prevention, psychological capacity (depression management), cognitive capacity, and caregiver support.

The portfolio emphasises that self-management support—providing older people with information, skills, and tools—is essential for person-centred care. Each programme has been tested in community settings, published in peer-reviewed journals, and shown to deliver positive outcomes when implemented with fidelity. Programmes such as the Chronic Disease Self-Management Program (available in English, Spanish, Portuguese, and French), Vivifrail, Otago, Tai Chi for Arthritis, and PEARLS are described with specific training requirements, personnel needs, materials, and evidence base.

An appendix provides a toolkit for organisations planning adoption, covering readiness assessment, community leadership, logic models, quality improvement, and the RE-AIM framework (Reach, Effectiveness, Adoption, Implementation, Maintenance) for planning and evaluation. The portfolio stresses that programmes require structured training, fidelity to design, adequate budgeting for sustainability, and integration into primary care to be cost-effective.

Key points

For clinicians — doses and thresholds as stated in the guideline

1. Chronic Disease Self-Management Program (CDSMP) is a 6-week, small-group workshop (10–14 participants, 2.5 hours/week) teaching problem-solving, action planning, and decision-making; peer leaders trained in a 4-day workshop facilitate sessions.
2. Vivifrail is a 12-week individualised multicomponent exercise programme (30–45 minutes/day) for persons ≥70 years; prescription is based on a balance, walking speed, and chair-stand test, with four exercise passport levels (A for disability to D for robust).
3. Otago Exercise Program comprises 17 strength and balance exercises done at home 3 times/week for 30 minutes plus walking 3 times/week for up to 30 minutes; delivered by trained physical therapists over 8 weeks with follow-up at 6 and 12 months.
4. Enhance Fitness is a multi-component group class (1 hour, 3 times/week) including warm-up (5–9 minutes), cardiovascular workout (20 minutes), strength training (20 minutes), and flexibility/balance; outcomes tested every 4 months.
5. PEARLS (Program to Encourage Active, Rewarding Lives) delivers 6–8 one-on-one sessions (50 minutes each) over 19 weeks using problem-solving therapy, behavioural activation, and pleasant activity scheduling, followed by monthly telephone follow-up for 3–6 months to manage depressive symptoms.
6. Tai Chi for Arthritis/Fall Prevention consists of 1-hour classes twice weekly for 8 weeks teaching 6 basic and 6 advanced Sun-style Tai Chi movements with breathing techniques; certified instructors trained by master trainers.
7. Evidence-based programmes require fidelity to design: structured training, scripted manuals, prescribed materials, and adherence to dosage (number and duration of sessions) to replicate proven outcomes.
8. Approximately 80% of functional declines due to chronic conditions are preventable; 30% of community-dwelling adults ≥65 years and 50% of those ≥85 years fall at least once yearly, with 95% of hip fractures resulting from falls.

Chronic Disease Self-Management Program (CDSMP) delivery formats and requirements

Table extracted from the guideline

Source: Pan American Health Organization, Portfolio: Evidence-based Programs for a Person-centered, Integrated Care for Older People at the Primary Health-care Level. Reproduced in summary form.

From the guideline

Verbatim

“Offering support for self-management is another tool for providing person-centered and integrated care to older adults.”

Editor’s perspective

Why this matters for Georgia and the region

Applicability

Georgia and the South Caucasus

Questions this guideline answers

Quick answers

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