Integrated Care for Older People(ICOPE)

The increasing ageing population in Sri Lanka has created a growing demand for healthcare services that address the complex medical, functional, psychological, and social needs of older persons. Many elderly individuals live with multiple long-term conditions (MLTCs) such as hypertension, diabetes mellitus, cardiovascular diseases, arthritis, chronic respiratory diseases, and other chronic illnesses that require continuous monitoring and coordinated management. In addition to these chronic diseases, older persons frequently experience age-related declines in nutrition, vision, mobility, mental well-being, and social functioning, which may negatively affect their independence and quality of life.

The MLTC Clinic and Integrated Care for Older People (ICOPE) Project at Chankanai Divisional Hospital aim to provide comprehensive, integrated, and person-centred care for older persons through systematic assessment, timely referrals, individualized care planning, and a variety of health-promoting activities. By addressing the medical, functional, psychological, and social needs of elderly individuals, the programme seeks to enhance healthy ageing, maintain independence, improve quality of life, and promote active participation in society.Through this integrated approach, the programme aims to improve quality of life, strengthen independence, and enhance the overall well-being of older persons in the Chankanai area

Referral System and Care

Following the comprehensive assessment process, findings are reviewed by the multidisciplinary healthcare team. Older persons identified with specific health concerns are referred to appropriate services for further evaluation and management. Referrals may be made for medical assessment, physiotherapy services, nutritional counselling, ophthalmology services, mental health support, social services, and other specialized healthcare services as required.

Based on the assessment findings, individualized care plans are developed to address the specific needs of each elderly participant. These care plans focus on maintaining functional ability, improving disease management, promoting healthy lifestyles, preventing complications, and enhancing overall quality of life. The multidisciplinary team works collaboratively to ensure continuity of care and regular follow-up.

Daily Activities

To promote healthy ageing and maintain functional ability, a range of daily activities has been planned for elderly participants. These include daily monitoring of vital signs such as blood pressure, pulse rate, respiratory rate, temperature, and blood glucose levels when indicated. Regular exercise sessions will be conducted to improve physical fitness, balance, flexibility, and mobility.

Counselling services will be provided to support emotional well-being and address psychosocial concerns. Routine medical examinations will be carried out to monitor chronic diseases and identify emerging health issues. Meditation sessions will be organized to promote relaxation and mental wellness, while music therapy activities will provide opportunities for emotional expression, cognitive stimulation, social interaction, and stress reduction.

Weekly Activities

Weekly MLTC clinic sessions will be conducted to review the health status of participants, monitor treatment adherence, and provide ongoing management of chronic conditions. Hobby-based activities will be organized to encourage creativity, self-expression, and social engagement among older persons.

Indoor games and recreational activities will also be conducted weekly to promote physical activity, cognitive stimulation, teamwork, and enjoyment while reducing social isolation.

Monthly Activities

Monthly programmes will be organized to strengthen community participation and promote healthy ageing. These programmes will include health education sessions focusing on nutrition, physical activity, disease prevention, medication adherence, mental health, and safety.

Annual Activities

Annual recreational trips will be organized to provide older persons with opportunities for relaxation, enjoyment, socialization, and exposure to new experiences. These activities are expected to contribute positively to mental well-being and quality of life.

An Annual Day Programme will also be conducted to celebrate the achievements of participants and recognize the contributions of caregivers, healthcare staff, volunteers, and community members involved in supporting the programme. The event will include cultural performances, recreational activities, and health promotion initiatives.