What are the 5 steps of ICOPE? A Guide to the WHO's Integrated Care Model

According to the World Health Organization (WHO), over 60 countries and regions are developing or implementing integrated care for older people (ICOPE) programs. The five-step ICOPE model provides a structured, person-centered approach to help health and social care services promote healthy aging by maximizing older people's intrinsic capacity and functional ability.

Quick Summary

The Integrated Care for Older People (ICOPE) framework involves five key steps: screening for declining intrinsic capacity, conducting a person-centered assessment, developing a personalized care plan, monitoring the plan, and engaging the community while supporting caregivers.

Key Points

• Screening for decline: The first step involves a quick check for declines in six domains of an older person's intrinsic capacity: locomotion, vitality, vision, hearing, cognition, and psychological well-being.

• Person-centered assessment: Following a positive screen, a comprehensive, in-depth evaluation is conducted in primary care to understand the individual's specific needs and health priorities.

• Personalized care planning: A collaborative process where the older person and their healthcare team define care goals and develop an individualized plan based on the assessment findings.

• Monitoring and referral: The care plan's implementation is monitored, with structured referral pathways connecting the individual to specialized geriatric care when required.

• Community engagement: The ICOPE framework extends beyond clinical care to involve community resources and support for both older adults and their informal caregivers.

• Proactive vs. Reactive Care: ICOPE shifts care from a reactive, disease-based model to a proactive approach focused on maintaining and optimizing intrinsic capacity for healthy aging.

What is the Integrated Care for Older People (ICOPE) model?

ICOPE is a public health strategy created by the World Health Organization (WHO) to address the needs of aging populations. It shifts the focus of care for older adults from managing specific diseases to optimizing their physical and mental capacities, known as 'intrinsic capacity'. This holistic, person-centered model is designed to help older people maintain their functional abilities and well-being for as long as possible. The following section details what are the 5 steps of ICOPE that guide this process.

Step 1: Screen for Declines in Intrinsic Capacity

The process begins with a brief, preliminary screening to identify older adults who may have declining intrinsic capacity (IC). This first step is crucial for early detection and can be performed by various health and social care workers or even trained volunteers. The screening tool typically assesses six domains of intrinsic capacity:

• Locomotion: Checking for signs of reduced mobility or balance issues.
• Vitality/Nutrition: Looking for unintentional weight loss or poor appetite.
• Vision: Testing for any visual impairments.
• Hearing: Conducting a simple test for hearing loss.
• Cognition: Assessing memory and orientation.
• Psychological Well-being: Screening for depressive symptoms or low mood.

A positive screening in any of these areas serves as a trigger for a more in-depth assessment in the next step.

Step 2: Undertake a Person-Centered Assessment

For those who screen positive in Step 1, a comprehensive, in-depth evaluation is conducted in a primary care setting. Unlike a standard medical examination, this assessment is person-centered and involves understanding the individual's specific needs, preferences, and priorities. This step involves confirming the presence and severity of the functional impairments identified during the screening. It also includes assessing chronic health conditions and evaluating the person's social care and support needs to create a complete picture of their situation.

Step 3: Develop a Personalized Care Plan

Based on the comprehensive assessment, the older person, their family, and their healthcare team work together to develop a personalized care plan. This plan is tailored to the individual's specific goals and priorities, focusing on optimizing their intrinsic capacity and functional ability. The care plan outlines evidence-based interventions and lifestyle changes. For example, if malnutrition is detected, the plan might include dietary advice or connecting the person with food delivery services. This collaborative approach ensures the plan is meaningful and achievable for the individual.

Step 4: Ensure Referral and Monitoring of the Care Plan

Implementing the care plan often requires coordination with various services and ongoing monitoring. This step involves establishing a strong referral pathway to specialized care, such as a geriatrician, if needed. Regular monitoring is essential to track progress, evaluate the effectiveness of interventions, and make any necessary adjustments to the care plan. This iterative process ensures the care remains responsive to the older person's evolving needs and helps them stay on track toward their health goals.

Step 5: Engage Communities and Support Caregivers

The final step recognizes that healthy aging depends on more than just clinical interventions. It involves engaging community resources and providing support to informal caregivers, such as family members. This includes connecting older adults with social support networks and community exercise programs to combat social isolation. For caregivers, it involves providing education, training, and support to prevent burnout and ensure they can continue their vital role. Strengthening this wider support network is crucial for sustaining the older person's well-being over the long term.

Comparison of Standard Care and the ICOPE Approach

Feature	Standard Care Model	ICOPE Model (WHO)
Focus	Primarily on disease management.	Primarily on intrinsic capacity and functional ability.
Assessment	Often fragmented, focusing on a single condition or symptom.	Holistic and person-centered, assessing multiple domains of intrinsic capacity.
Initiation	Triggered by a specific medical problem or diagnosis.	Initiated by proactive screening for early signs of decline.
Care Plan	May consist of multiple, uncoordinated plans from different specialists.	A single, personalized, and coordinated care plan developed collaboratively.
Referrals	Ad-hoc and often siloed to different departments.	Structured referral pathways that link primary and specialized care.
Support System	Limited engagement with external support systems.	Integrates community services and supports caregivers as key components.
Goal	Treating and curing disease.	Maintaining well-being and optimizing functional ability.
Role of Individual	Passive recipient of medical treatment.	Active participant and decision-maker in their care journey.

The importance of ICOPE for healthy aging

The ICOPE framework represents a significant shift in how healthcare systems approach the needs of older people. By proactively screening for declines in intrinsic capacity, the model aims to intervene early, potentially reversing or delaying the onset of dependency. The person-centered philosophy ensures that care plans reflect the older adult's individual preferences and priorities, promoting greater engagement and adherence. Furthermore, by incorporating community and caregiver support, ICOPE acknowledges the crucial social context of an older person's life, creating a more comprehensive and sustainable system of care.

Conclusion

The World Health Organization's ICOPE model offers a robust and structured, five-step pathway for promoting healthy aging. From initial screening for intrinsic capacity declines to developing personalized care plans, monitoring progress, and supporting communities and caregivers, the process ensures older adults receive integrated, person-centered support. By moving beyond traditional disease-focused care, ICOPE helps healthcare systems focus on maximizing older people's abilities and enhancing their overall well-being. The result is a more compassionate and effective approach that enables older adults to live independent, fulfilling lives for longer.

For more detailed information and resources on implementing the ICOPE model, visit the official World Health Organization page dedicated to Integrated care for older people (ICOPE).

What are the 5 steps of ICOPE? Explained

The 5 steps of ICOPE are:

1. Screening: A quick check for declines in six areas of intrinsic capacity (locomotion, vitality, vision, hearing, cognition, and psychological well-being).
2. Assessment: An in-depth, person-centered evaluation in primary care to confirm any issues found during screening.
3. Care Plan: The collaborative development of a personalized care plan with evidence-based interventions.
4. Monitoring: The ongoing tracking of the care plan's progress and referral to specialized services when necessary.
5. Community Engagement and Caregiver Support: Involving community resources and providing support to family and other caregivers.

Frequently Asked Questions

What is intrinsic capacity (IC) in the ICOPE framework?

Intrinsic capacity is a composite of all an individual's physical and mental capacities, including their mobility, vitality, cognitive ability, and psychological state. The ICOPE framework aims to maintain and optimize this capacity to enable healthy aging.

Who developed the ICOPE model?

The ICOPE model was developed and published by the World Health Organization (WHO) as part of its public health strategy to promote healthy aging worldwide.

Can non-healthcare professionals perform the initial ICOPE screening?

Yes, the initial screening (Step 1) is designed to be a brief assessment that can be conducted by various health and social care workers, and even trained volunteers, to identify potential areas of concern.

How does the ICOPE model differ from standard geriatric care?

The ICOPE model is more holistic and proactive than standard geriatric care. It focuses on maintaining an older person's intrinsic capacity and functional ability through a person-centered, five-step process, rather than primarily on managing specific diseases reactively.

What happens after an issue is identified in the ICOPE screening?

If an issue is identified during the initial screening (Step 1), the person moves on to a more comprehensive, in-depth assessment in primary care (Step 2) to confirm the impairment and determine the root cause.

What role do caregivers play in the ICOPE process?

Caregivers and family members are supported throughout the ICOPE process, especially in Step 5. This involves providing them with training, support, and psychological interventions to prevent strain and ensure they can effectively help care-dependent older adults.

What happens if a care plan is not working effectively?

During the monitoring phase (Step 4), if a care plan is not achieving the desired outcomes, the healthcare team can make necessary adjustments. This ongoing monitoring ensures the care remains responsive and effective for the older person.