Effectiveness of integrated person‐centered interventions for older people's care: Review of Swedish experiences and experts’ perspective

Older adults have multiple medical and social care needs, requiring a shift toward an integrated person‐centered model of care. Our objective was to describe and summarize Swedish experiences of integrated person‐centered care by reviewing studies published between 2000 and 2023, and to identify the main challenges and scientific gaps through expert discussions. Seventy‐three publications were identified by searching MEDLINE and contacting experts. Interventions were categorized using two World Health Organization frameworks: (1) Integrated Care for Older People (ICOPE), and (2) Integrated People‐Centered Health Services (IPCHS). The included 73 publications were derived from 31 unique and heterogeneous interventions pertaining mainly to the micro‐ and meso‐levels. Among publications measuring mortality, 15% were effective. Subjective health outcomes showed improvement in 24% of publications, morbidity outcomes in 42%, disability outcomes in 48%, and service utilization outcomes in 58%. Workshop discussions in Stockholm (Sweden), March 2023, were recorded, transcribed, and summarized. Experts emphasized: (1) lack of rigorous evaluation methods, (2) need for participatory designs, (3) scarcity of macro‐level interventions, and (4) importance of transitioning from person‐ to people‐centered integrated care. These challenges could explain the unexpected weak beneficial effects of the interventions on health outcomes, whereas service utilization outcomes were more positively impacted. Finally, we derived a list of recommendations, including the need to engage care organizations in interventions from their inception and to leverage researchers’ scientific expertise. Although this review provides a comprehensive snapshot of interventions in the context of Sweden, the findings offer transferable perspectives on the real‐world challenges encountered in this field.


Introduction
In recent decades, evidence from the aging research field has demonstrated the need for a shift from traditional, single-disease-focused healthcare to a holistic, person-centered approach that considers the entirety of an individual, encompassing their medical, social, and psychological needs simultaneously [1,2].This approach requires the integration of different disciplines and care settings, which have traditionally operated in a fragmented manner.Older adults often have complex health needs that lead to interactions with multiple specialists and care providers, requiring effective communication and coordination [2,3].These needs can be met by integrated personcentered care models, which ensure that older people's health is comprehensively addressed, promoting improvements in health and well-being, while simultaneously preserving their autonomy and dignity [4,5].
The Swedish medical and social care system is decentralized, and responsibilities are divided among several regions and municipalities in charge of delivering various components of medical and social care services, respectively [6].Although the country has publicly funded universal health coverage, it is confronted with several challenges that are common to many other developed heath systems, including a lack of coordination among healthcare providers and between medical and social care settings, variable care quality among different regions and municipalities, and increased reliance on informal caregivers for caring for the oldest old [7].Several initiatives have been directed toward promoting better integration of care, including the Good and Close Care 2030 (God och nära vård) program enacted in 2018, which aims to integrate services for seamless and better coordinated care [8].However, the most recent evaluations report minimal to no changes from the patient, system, and professional perspectives and highlight that-despite existing political and strategic support-a lack of resources in primary care might hinder the transition into actual good and close care in the coming years [9,10].
The concepts of person-centered and integrated care have been defined in multiple ways.Briefly, person-centered care implies that a person's values and preferences guide their care, supporting their realistic health and life goals [11], whereas integrated care involves managing and delivering healthcare services in a coordinated manner, covering everything from prevention to treatment and beyond, tailored to the individual's needs and resources throughout their life [12].The endorsement of integrated and person-centered care is highly prioritized in the international health-policy agenda due to its potential to promote equitable access to quality care worldwide.Recent recommendations have emphasized the need to combine these two concepts and move forward toward people-centered integrated care delivery [13].The Integrated Care for Older People (ICOPE) framework by the World Health Organization (WHO) provides guidance for implementing interventions at the micro (patient), meso (service), and macro (system) levels [14].In parallel, a WHO practice brief linked to the Integrated People-Centered Health Services (IPCHS) framework provides eight key practice areas that need to be optimized to support interactions among multiple providers within and across interdisciplinary teams at different care settings [15].
In this paper, we aim to evaluate Swedish experiences of integrated person-centered care for older people by conducting: (1) a scoping review of the effectiveness of interventions in Sweden, structured according to the ICOPE and IPCHS frameworks, and (2) a qualitative analysis of a workshop held in Stockholm in March 2023, where 17 experts discussed specific challenges, barriers, and enablers linked to intervention design, evaluation, and implementation.

Methods
This review was written based on the symposium and expert workshop "Person-centered and integrated care for older people: Successful experiences across Sweden", which took place on March 21-22, 2023, at Karolinska Institutet, in Stockholm, Sweden (https://news.ki.se/symposiumon-person-centred-and-integrated-care-for-olderpeople).The manuscript was structured based on the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews checklist [16].

Scoping review
Eligibility criteria.We included original, peerreviewed articles published in Swedish or English between 2000 and the search date (March 10, 2023).The identification of person-centered or integrated (or both) interventions was determined if either: (1) the authors "labeled" the interventions as such themselves, (2) specific keywords were used to describe the interventions, or (3) the descriptions met the definitions proposed by the University of Gothenburg Center for Person-Centered Care (GPCC) for person-centered interventions [17], and the Swedish Agency for Health and Care Services Analysis (Myndigheten för vårdoch omsorgsanalys) for integrated care [18].All types of study designs were considered, as well as articles examining implementation outcomes, according to Proctor et al.'s framework [19].The full list of inclusion and exclusion criteria is summarized in Fig. S1.
Information sources and search strategy.We searched MEDLINE on March 10, 2023, to identify potentially relevant publications.The search used a combination of controlled vocabulary terms (e.g., MeSH terms) and relevant free-text keywords related to the research topic, which were identified by searching previous literature.The full search algorithm is presented in Table S1.All experts attending the workshop were also contacted to check the completeness of the included publications.Additionally, a manual search of the reference lists of selected publications was conducted.
Selection of studies and data charting.The titles and abstracts of all references, as well as the full texts of preliminarily selected articles, were independently screened against the eligibility criteria by at least two authors using the Covidence software [20].Any dissent in screening was resolved by discussion moderated by a third author.Two authors extracted data from the studies, and a third author checked and confirmed the accuracy of the data.Information extracted from the articles included findings related to the outcomes of interest, as well as details about the samples and intervention design/content.Of note, implementation outcomes were mapped using an existing framework as follows: acceptability, adoption, appropriateness, costs, feasibility, fidelity, penetration, and sustainability (see definitions in the original manuscript by Proctor et al. [19]).

Expert discussion
Four main discussion points were raised in the workshop: (1) definitions of person-centered and integrated care, (2) intervention design, (3) intervention evaluation, and (4) implementation/scalability.The list of the 17 experts participating in the discussion and the detailed questions posed in the workshop are available in Table S2.Voice recordings were made and transcribed verbatim based on explicit consent from the participants.The transcript was thematically summarized.

Results: scoping review
Our MEDLINE search resulted in 1832 unique records, of which 1634 were excluded at the stage of title and abstract screening (Fig. S2).Of the 198

IPCHS practice area Description
1. Continuity with a primary care professional A positive, continuing relationship between the patient and the named primary care professional within the extended primary care team.

Collaborative planning of care and shared decision-making
Involving patients, family and caregivers in holistic, anticipatory planning of care with care "navigators", "connectors," or "health coaches" to help them manage their conditions, build social connections, and improve their understanding and adherence to medicines.

Case management for people with complex needs
Care and support are planned, reviewed, and coordinated by a practitioner case manager, who follows care over time and addresses both the physical and the mental health needs of people with complex multiple conditions or complicated circumstances.

Collocated services or a single point of access
A single-entry point to access physically collocated services or to access staff and services linked by online or telephone systems.

Transitional or intermediate care
Teams manage transitions between hospital and home and offer urgent community assessment, treatment, rehabilitation, or palliative and end-of-life care as alternatives to readmission to hospital.The teams also help people to understand and manage their medicines at home.articles that underwent full-text screening by at least 2 authors, 67 were included.Six additional articles were identified by contacting experts in the field, bringing the total up to 73 publications.We summarized the evidence on health and service use outcomes (55 publications), as well as implementation outcomes (18 publications) pertaining to 31 unique interventions in Sweden.All publications were written in English.
Interventions were carried out predominantly in urban settings, concentrated around two large cities in Sweden: Gothenburg and Stockholm (Fig. 1).Most interventions focused on specific diseases, such as heart failure and chronic obstructive pulmonary disease, although 13 interventions addressed a broader group of geriatric patients, emphasizing those with multimorbidity and frailty.Interventions primarily occurred in hospital, post-discharge, and home care settings, with fewer instances in care homes and primary care.The most frequently involved professional was a nurse, followed by occupational therapists and physiotherapists.Most interventions involved medical professionals exclusively, and six involved social workers.The predominant type of study design was a non-randomized controlled trial (Table 2).
Regarding effectiveness-considering every publication by which the outcome was measured and, thus, accounting for the fact that some interventions were assessed by multiple publications-, in 15% of the publications measuring mortality, a significant protective effect was observed.Subjective health outcomes showed improvement in 24% of publications, morbidity outcomes in 42%, disability outcomes in 48%, and service utilization outcomes in 58% (Table 3).For implementation outcomes, acceptability of the intervention-defined as the perception that a given treatment, service, practice, or innovation is agreeable, palatable, or satisfactory [19]-was most commonly exam-  • The PCC-HF study (a study employing personcentered care in managing patients with chronic heart failure) showed reduced hospital stay and better preservation of activities of daily living (ADLs) but found no differences between the intervention and control groups in terms of health-related quality of life (HRQoL) or readmission rates after six months [22].Patients in the intervention group were discharged earlier, and the process went smoother than for those in the control group [23].The intervention was associated with lower costs and more health benefits than conventional care [24].According to the managers involved in the intervention, facilitators to implementation included the organizational culture, distribution of power, teamwork, and efficiency [25].However, there was a concern that the implementation process was incomplete and that it could regress to previous work routines [25].

Five interventions on collaborative planning and shared decision-making (practice area 2)
• The intervention Person-centered care for patients undergoing total hip arthroplasty showed shorter hospital stay but did not find significant differences in ADLs and HRQoL [26].
• A client-centered program focusing on energy conservation for people with heart failure failed to find statistically significant differences in terms of depression and fatigue severity between the intervention and control groups [27].The intervention was positively assessed by staff and clients, with notable findings on enhanced collaboration and new knowledge [27].However, the staff questioned the possibility of long-term use in clinical practice [27].
• The intervention Coordinated geriatric care with increased patient participation and goal-setting for patients with hip fracture demonstrated a faster recovery in ADLs in the intervention group but failed to show significant differences between groups for the remaining outcomes,  [22][23][24][25] PCC for patients undergoing total hip arthroplasty [26] A client-centered energy conservation program for people with CHF [27] Coordinated geriatric care with increased patient participation and goal setting [28] DCI-SWE: Swedish Dignity Care Intervention [29,30]

ICOPE macro (system) level interventions
Nurse-led heart failure clinics in primary care [91] TioHundra integrated healthcare organization [92][93][94] Note: The row shading implies that interventions belong to the same IPCHS thematic cluster.Abbreviations: IC, integrated care; PCC, person-centered care; CHF, chronic heart failure; CGA, comprehensive geriatric assessment: ADL, activities of daily living, ICOPE: Integrated Care of Older People, IPCHS: Integrated People-Centered Health Services.such as functional balance and physical performance measures [28].
• The Swedish Dignity Care Intervention (DCI-SWE) targeting palliative care patients did not show significant changes in quality of life (QoL) [29].The intervention was reported to be acceptable by both patients and their relatives, as it provided the needed structure for palliative care.Facilitators included sufficient time, support from managers, and positive effects on patients; barriers included lack of staff, fear of change, and interruptions from family members [29,30].

Two interventions on collaborative planning with a case management element (practice areas 2 and 3)
• A case management intervention for older people with frequent emergency department visits, which included a personalized plan and coordination of hospital care, showed a significant reduction in hospitalization rates [31].However, there were no differences in the number of days in hospital nor the risk of death between the intervention and control groups [31].The intervention did not result in significant differences in total healthcare costs between the intervention and control groups [31].
• The RESPECT intervention-a person-centered support program aiming to empower patients with cancer to deal with treatment side effectsshowed no significant differences between the control and intervention groups after three months with regard to the number and severity of symptoms [32].The intervention showed high recruitment and retention rates, but none of the patients made contact with the intervention team after the intervention was completed, raising concerns regarding sustained effects [32].

Four interventions on collaborative planning within transitional care (practice areas 2, ±3, and 5)
• A client-centered ADL stroke rehabilitation intervention was examined in six publications.In a feasibility trial, there were no differences in ADL, stroke impact scale (SIS) measures, functional dependence, life satisfaction, or use of services [33].Similarly, in a pilot trial, there were no statistically significant differences in outcomes for ADLs, functional dependence, life satisfaction, or SIS [34].In a subsequent randomized controlled trial, the intervention failed to show significant differences, apart from the domain of emotional health in SIS [35].In a multicenter trial, there were no differences between the groups regarding changes in independence in ADLs or life satisfaction during the first 12 months [36].A secondary analysis of the trial showed that patients in the intervention group had a shorter length of hospital stay and fewer outpatient contacts [37].
Finally, in the most recent cluster-randomized trial with a five-year follow-up, the intervention group did not demonstrate significant improvements for the primary outcome SIS nor for secondary outcomes such as independence in ADLs and life satisfaction [38].The intervention was accepted by patients, although these were involved in other simultaneous studies, making it difficult to discern effects [33].The caregiver burden was not improved by the intervention, and the intervention was too strenuous for some participants [34].In a separate caregiver interview study, there were no differences in the outcomes of caregiver burden, provision of informal care, perceived participation in everyday occupations, or life satisfaction [39].In a later publication, anxiety and depression scale scores were significantly higher for caregivers in the control group [38].Finally, in an interview study with managers and staff, some therapists thought that the intervention was too limited and difficult to implement.Managers reported some barriers, including reorganization, low staffing, and recruitment issues during the implementation [40].
• An empowerment intervention for rehabilitation of patients with hip fracture demonstrated a significantly shorter length of hospitalization in the intervention group, although mortality rates did not differ [41].
• The Gothenburg Very Early Supported Discharge study did not show significant differences between the stroke groups regarding anxiety at three-or 12-months poststroke [42].The overall disability was significantly lower in the intervention group three months poststroke, but not at one-year poststroke [42].
• An intervention exploring the effects of a personcentered information and communication intervention for preparedness for colorectal cancer surgery and recovery found no significant difference in QoL between the intervention and control groups [43].However, the intervention group had a significantly shorter hospital stay [43].

Four interventions on collaborative planning with comprehensive patient pathways (practice areas
±1, 2, ±5, and 6) • A multidisciplinary CGA-based postoperative rehabilitation program for older people with femoral neck fractures demonstrated better ADL independence and mobility measures in the intervention group but failed to show differences in mortality compared to the control group [44].In a subgroup analysis of the same trial pinpointing older people with femoral neck fracture and concomitant dementia, the intervention group had fewer postoperative complications and gained ADL independence faster but was not different from the control group in terms of mortality, readmissions, or length of stay [45].
• The intervention CGA-Swed: Comprehensive geriatric assessment in a Swedish acute hospital for frail older people did not lead to significant differences in ADLs or self-rated health [46].However, the intervention was associated with a higher proportion of patients being prescribed antidepressants [47].In a recent study, the intervention reduced frail older people's dependence in ADL, but there were no statistically significant changes for self-rated health or frailty at the 12-month follow-up [48].The CGA-Swed was proven to be feasible [49], patients reported feeling respected as a person [50], and had a higher probability of having received written information on their care [46].
• The intervention Comprehensive geriatric assessment in acute hospital care, which targeted frail, hospitalized older patients, showed that patients in the intervention group had a lower risk of decline in ADLs and in the degree of frailty [51], lower mortality rate, better HRQoL [52], and better physical fitness [53].The intervention was found to be less costly and more effective than usual care, and patients reported high satisfaction with the received care [54, 55].
• An intervention on comprehensive geriatric assessment in primary care targeting older peo- • An project employing a home intervention system, OPTILOGG, for managing heart failure symptoms showed that the intervention group had significantly higher scores on HRQoL measures and spent fewer days in hospital [58].
• A person-centered care intervention delivered using structured telephone support, Care4ourselves, was assessed in several studies.There were no differences in hospitalization and mortality rates between the intervention and control groups [59].However, self-reported fatigue improved in the intervention group in one out of five dimensions (i.e., "reduced motivation" dimension) [60].In a version of the intervention comprising telephone support plus a digital platform, the hospitalization and mortality rates neither differed between the groups [61], but at both three-and six-month follow-ups, the intervention group improved significantly in terms of ability to control one's illness [62].The intervention showed higher cost-effectiveness than usual care [63].
• The F@ce intervention-using information and communication technology for stroke rehabilitation-was assessed in an uncontrolled feasibility study [64].Several participants showed clinically meaningful improvements in SIS and life satisfaction, whereas there were no changes in anxiety, depression, or fatigue [64].The intervention showed good adherence and acceptability, but the fidelity of the intervention required some improvementfor example, more time for workshop planning and preparation and better procedures for following-up the intervention [64].
• The ASSIST intervention-a reablement program for older adults who were discharged from the hospital into home care-showed improvements in HRQoL but failed to show differences between the intervention and control groups in terms of ADLs, anxiety, depression, and life satisfaction [65].The intervention was shown to be acceptable to patients and feasible for scale-up and implementation in the Swedish context [65].

Other
• One intervention covered the areas of collaborative care (practice area 2) and capacity building of the workforce through comprehensive education of staff (practice area 8).This was the person-centered incontinence care intervention for older adults with cognitive decline in residential care, which showed an increase in residents' QoL in the intervention group compared to the baseline and control group [66].

Summary of nine interventions on the ICOPE meso (service) level
Seven interventions on collaborative planning through case management and care continuity (practice areas 2, 3, ±4, 5, and 6) • The Göteborg 70+ Stroke Study: Integrating stroke care into the care continuum was not associated with better outcomes in terms of a greater number of surviving patients living at home, better ability to perform ADLs, or higher QoL [67].An article examining healthcare costs of the intervention reported that the total costs during the first year poststroke did not differ significantly between the intervention and control groups [68].
• In an article on the Integrated care pathway for acute hip fracture, the intervention group had a significantly shorter length of hospital stay, shorter time to first ambulation, fewer pressure wounds, and fewer medical complications than the comparison group [69].Another publication on the same intervention reported that ADL outcomes were more favorable in the intervention group [70].The intervention was cheaper and more effective than usual care [71].
• The continuum of care intervention for frail older people was assessed in three publications over the years.An earlier randomized controlled trial reported that the intervention group had higher odds of improved ADL independence compared to the control group at both three-and 12month follow-ups but showed no significant differences between the groups in terms of changes in frailty levels [72].A subsequent article reported that life satisfaction was higher among patients in the intervention group [73].Finally, another paper reported that the intervention was associated with improvements in self-rated health and a reduction in symptoms [74].According to the staff participating in the intervention, the different cultures of organizations must be considered when implementing a new model.The role of upper management emerged as very important [75].
• The Frailty Intervention Trial (Age-FIT), which explored the effects of comprehensive ambulatory geriatric assessment for frail older people with multimorbidity, reported no differences in the number of hospitalizations or measures of HRQoL, but the intervention group stayed in the hospital for a shorter time and demonstrated a trend of reduced mortality [76].A long-term evaluation of the same intervention reported an increase in mean survival time in the intervention group [77].The mean number of hospitalizations or care home transfers during follow-up did not differ significantly between groups, whereas the number of days in the hospital was significantly lower in the intervention group [77].The Age-FIT did not show differences between the intervention and control groups regarding prevalence, burden, or trajectory of symptoms in another study [78].The same intervention was found not to affect the causes of death [79], but at 24-months postintervention, there was a significantly smaller proportion of frail and deceased patients and a significantly higher proportion of pre-frail patients in the intervention group [80].The Age-FIT was shown to be equivalent to usual care in terms of total costs for medical and social care [76].However, patients in the intervention group had significantly more visits to physicians and other staff and lower costs for hospital care than patients in the control group [77].
A later cost-effectiveness analysis of the Age-FIT reported that, although the intervention was associated with higher costs, participants in the intervention group survived longer [81].

Other
• A coordinated hip fracture care model, addressing the areas of transitional care (practice area 5) and comprehensive care along the entire pathway (practice area 6), demonstrated a shortening of the hospital stay, but there was no difference between the groups in terms of patient-reported QoL [89].The cost of care was significantly lower for patients in the intervention group [89].
• A knowledge-based palliative care intervention for care home residents, addressing the areas of collaborative planning of care (practice area 2) and building workforce capacity (practice area 8), did not find between-group differences in QoL [90].

Summary of two interventions on the ICOPE macro (system) level
• One publication on nurse-led heart failure clinics in primary care settings reported that this intervention significantly reduced the number of heart failure-related hospital admissions, hospital days, and emergency room visits [91].
• According to two publications assessing the integrated care model for people aged over 65 years implemented by the TioHundra organization, the care model was associated with a decrease in the rate of emergency department visits [92] and the rate of hospitalization for ambulatory care sensitive conditions [93], compared to pre-intervention levels.However, the difference was not statistically significant when compared to changes in the rest of Stockholm county [92] and a matched control area [93].Another article examining Tio-Hundra found that patients undergoing total hip replacement in the integrated care system showed no differences across studied health outcomes compared to those receiving standard care [94].

Results: expert discussion
In Table 5, we present findings from the expert discussion by themes (four main discussion points raised in the workshop, see Table S2) and subthemes (consistent categories of topics mentioned by the experts), supported by verbatim quotes.

Discussion
In this review, which draws from a workshop involving experts in the field, a strategic choice was made to examine care interventions using the ICOPE and IPCHS frameworks from WHO involving both people-centered practice (which extends the concept of person-centered care to individuals, families, communities, and the society) and integrated care elements [13].This decision was dictated by the need to account for heterogeneous definitions and diverse interventions [12,95], as well as the conceptual development of personcentered integrated care models [4].Taking the Swedish experience as a case study, we have derived some key recommendations linked to intervention content, design, and implementation (Fig. 2).
Theoretical frameworks were rarely used in the included Swedish interventions.For personcentered interventions, as expected by our choice of definitions, the GPCC framework was predominant [17].It is reasonable to assert that the GPCC We immediately got a little dissonance in our group because some of us said that culture must be set on the macro level and others thought it must happen at ground level, among people.

Intervention design
Participatory research with patients is vital

It's so important to really listen if the person wants to be involved in co-design; […] they maybe feel very uncomfortable participating as an older person. People with cognitive difficulties
should not be excluded Too often there is exclusion criteria for people with cognitive disabilities, but the results are very often used for that group.

Independent advocates for older people with communication impairment
Older people who have communication or sensory impairments might need an advocate to ensure that care is safe and appropriate for them and in their best interest.

Educating professions in silos hinders interdisciplinary research
There is a lack of interdisciplinary education of professions.One facilitator could be a transdisciplinary ambassador at the clinics.Cooperation among academia, care providers, and care quality experts for true co-design It would be exciting to test different kinds of rotation employments; for example, I as a healthcare professional would work both within patient care and in the municipality, as part of a chain.

Intervention evaluation
Multiple outcomes and their synergies should be considered

It's the need of having outcomes in numbers and in stories […]
, spanning the personal, relational, and community dimensions. (Continued)

Intervention effectiveness
The evidence supporting the effectiveness of interventions on health outcomes was generally weak.Our analysis did not reveal distinct patterns indicating the superiority of certain IPCHS thematic clusters over others.The IPCHS practice brief denotes that continuity and care coordination have the greatest impact when different practice areas are delivered in a "bundle" along the care pathway [15].Indeed, in our review, interventions that addressed more IPCHS priority practice areas, e.g., those that were based on the comprehensive geriatric assessment, tended to exhibit greater effectiveness.The mixed picture on intervention effectiveness can be attributed to various factors.
First and foremost, our review focused primarily on health-related and service utilization outcomes.
However, the studies included in our analysis also covered additional outcomes, such as patient satisfaction, self-efficacy, and dignity.These alternative measures may be equally pertinent when evaluating the effectiveness of such interventions.
During discussions with experts, the significance of patient-level subjective outcomes-such as feelings of loneliness and dignity-was underscored.Notably, certain service use outcomes-such as length of hospital stay and rate of hospitalizationwere more consistently positively affected by the interventions.This has been suggested in previous research.A review of integrated care interventions for older people found that interventions decreased hospital readmission rates and length of stay but did not affect mortality [99].An umbrella review of 50 systematic reviews reported that multidisciplinary teams and chronic integrated care models are associated with reduced costs and service use [100].A review of 55 person-centered interventions concluded that although most of the interventions did not improve health outcomes, some shortened the hospital stay and reduced the costs of care [101].In addition, we focused on older people, often with a high disease burden.The failure to demonstrate between-group differences in health outcomes could also be attributed to the limited potential for improvement in this population.
Poor evaluation practices may additionally underlie the discordance among our effectiveness findings.For example, as discussed by experts, the choice of outcome measures and timepoints for assessment in complex interventions warrants more attention and tailoring.One comprehensive approach for evaluating complex interventions such as those examined in our review is the realist evaluation.Realist evaluation is increasingly applied in the appraisal of complex healthcare interventions as it seeks to provide a more explicit and in-depth understanding of what works, for whom and in what circumstances [102].This methodology is particularly valuable for knowledge translation and the adoption of successful interventions [103].Another complementary approach for identifying relevant outcomes is contribution analysis [104], a theoretical framework for testing complex interventions that employs a theory of change to identify the most relevant outcomes across various impact levels (such as personal, relational, community, and societal levels).This technique might be more relevant and effective than exclusively targeting improvements in the health and functional outcomes of older people.Implementing these holistic methods would entail using diverse data sources and incorporating mixed-method study designs, which is not free from challenges.Nevertheless, these and similar approaches hold the potential to better capture the reality of what a complex multicomponent intervention can achieve, and may help in moving beyond arbitrarily defined health and service use outcomes that could be less meaningful to the end users.
There is also much room to improve publication practices.Promoting publication of study findings was underscored in the expert discussions.It is important to acknowledge that our group is aware of several relevant interventions in this field that have not published their effectiveness results up to our search date.To uphold high-quality research and evaluation standards, we strongly encourage researchers and professionals in the field to plan for the publication of their study findings in peer-reviewed journals in advance.It is also recommended that funding agencies take evaluation and knowledge mobilization plans into consideration.

Intervention implementation
The lack of participatory approaches (patient and public involvement, PPI) across interventions was striking.It is important to note that PPI is relevant to every stage of the process, from intervention design to evaluation and implementation.Thus, by excluding end users from the initial designrelated stages, the adoption of the intervention is jeopardized.According to a systematic review of 66 studies on medical and social care, involvement of end users may lead to better dissemination and implementation of research findings because of their influence in the community [105].However, researchers report that the main barriers to incorporating PPI in meaningful ways are lack of finance and time [106].We believe that PPI should become a mandatory component of intervention and practice planning, starting with funding bodies and eventually becoming an integral part of day-today operations within medical and social care.
Across implementation studies linked to the included interventions, cost analyses revealed overwhelmingly favorable results, demonstrating cost savings mainly by reducing hospital costs.In addition, most interventions were deemed acceptable and favorable by patients, their families, and staff.The expert discussions as well as our review findings concerning implementation outcomes underscore the requirement for strong managerial and executive support.The engagement of intervention staff and active involvement of upper management stakeholders are pivotal factors in ensuring the sustainability and scalability of interventions.Experts frequently cited the lack of shared ownership over interventions as a key reason for failure to expand successful practices.To ensure post-intervention sustainability, it is crucial for financial bodies and care organizations to engage in projects from their inception, leveraging on the expertise of researchers in conducting intervention studies rigorously.This collaborative approach fosters long-term viability and promotes knowledge sharing among the scientific community.The concepts of person-centeredness and care integration should also permeate the field of education, where the siloed training of professional disciplines was identified as an important barrier to providing high-quality, integrated care.

Strengths and limitations
We believe that the attempt to review the evidence on both person-centered and integrated care interventions is a strength of this study.Moreover, we position the review's findings based on insights from expert discussions in these areas.Importantly, this workshop set the scene for a network of Swedish experts on person-centered and integrated care, paving the way for future collaborations.Although this review provides a comprehensive snapshot of published research and study characteristics in the country context of Sweden, the findings offer valuable and transferable perspectives on the practical challenges and realworld barriers encountered in this field.
This study had several important limitations.First, we employed a scoping review methodology and, thus, did not assess the quality of the included studies.This might be problematic, as some studies did not use a randomized controlled design, the gold-standard to prove intervention effectiveness.The decision to exclude unpublished or "gray" literature may result in our findings being somewhat incomplete.Nevertheless, we chose to maintain a focus on peer-reviewed material, which helped ensure a certain level of quality of the evidence among included studies.The use of the internationally recognized ICOPE and IPCHS frameworks to map the interventions mitigated some of the heterogeneity identified.Moreover, although this review provides a broad overview of the state of evidence on integrated person-centered care interventions in Sweden, we believe that a more in-depth disease-and intervention-specific examination of these studies is essential to draw conclusions on their effectiveness.As for the second part of the paper, the workshop with experts was time-limited, and we were only able to tackle selected topics, preventing us from providing in-depth insights across all potential matters in the field.

Conclusion
Our comprehensive review of 31 interventions for older people's care in Sweden highlights the high acceptability and efficiency of integrated personcentered care approaches in this population group.Yet, these strategies often fail to produce consistent improvements in health-related outcomes.To advance research and practice, future interventions should aim to be more comprehensive, covering not only the areas of person-centered practice but also those linked to care continuity and coordination across services and systems.Interventions should strive to involve both medical and social care, to be anchored in primary care, and to target higher meso-and macro-levels of integration.Moreover, recognizing the synergies between person-centered and integrated care approaches and moving toward people-centeredness is crucial.Assessing personal, relational, community, and societal outcomes is warranted.For successful implementation and scalability, strong support from the managerial and executive levels is essential, along with the adoption of participatory designs.Early and active collaboration between researchers and care organizations is decisive to produce high-quality research and to ensure longterm sustainability.The alignment of educational practices with the evolving health and care landscape is paramount for overcoming barriers and delivering truly integrated person-centered care.
6. Comprehensive care along the entire pathway Comprehensive managed care models provide care coordination along the entire pathway, from home, community services, ambulatory, and emergency care to hospital care.7. Technology to support continuity and care coordination The availability of information and communication technologies that support the management of people's care makes it easier to ensure continuity and care coordination.8. Building workforce capability Education and training are required to strengthen the knowledge, confidence, skills and competence of patients, families, volunteers, communities, and all staff involved in delivering continuity and care coordination.Source: Adapted from Integrated Care for Older People, implementation framework guidance for systems and services (2019) and Continuity and coordination of care: a practice brief to support implementation of the World Health Organization (WHO) framework on Integrated People-Centered Health ervices (2018).

Fig. 1
Fig. 1 Map of Sweden showing where the 31 interventions took place between January 2000 and March 2023 (NB: some interventions had more than one location involved).A darker shade of green represents a higher number of interventions taking place in that geographical area.

Fig. 2
Fig. 2 Summary of key recommendations considering the findings from both the scoping review and the expert opinion from workshop discussions.

Table 1 .
Definitions of Integrated Care for Older People (ICOPE) levels and the list of Integrated People-Centered Health Services (IPCHS) priority practice areas

Table 3 .
Effectiveness and implementation outcomes of interventions Abbreviations: ADLs, activities of daily living; IADLs, instrumental activities of daily living; HRQoL, health-related quality of life.*Outcome counted only once per intervention, regardless of number of publications reporting it.**Outcome counted every time it was measured in all publications pertaining to one same intervention.

Table 5 .
Findings from the experts' workshop