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care coordinator, care management, case management, community care center, high-need older adults



  1. Hsu, Hui-Fen
  2. Chen, Kuei-Min
  3. Chen, Yu-Ming
  4. Chang, Chiang-Ching
  5. Chen, Meng-Chin
  6. Kuo, Chuan-Feng


Background: High-need older adults have multiple needs and require different types of care services. Care coordinators in community care centers in Taiwan, however, often experience difficulties in providing sufficient care services because of the inadequate capacity of case management.


Objective: The aim of this study was to develop a realistic care delivery model for the care coordinators to manage the care of high-need, community-dwelling older adults.


Methods: Focus-group interviews concerning elements and process for establishing a care delivery model were conducted with 12 care management experts in two groups: the practical work group (three registered nurses and three social workers) and the care management group (three care managers and three care management supervisors). The interviews were video-recorded and subjected to content analysis.


Results: A five-stage care delivery model was formulated: case screening, case assessment, care plan, care delivery, and follow-up evaluation. Six types of high-need older adults were identified: those living with disability, solitude, dementia, depression, elder abuse, and poverty. A list of categorized care services, including care resources, social welfare resources, and caregiver resources, was then used as a guide for case management and care delivery.


Discussion: The developed model-consisting a classification of services for different types of high-need older adults-serves as a guide for care coordinators in community care centers to make better decisions on service linkages, resource management, and care plan monitoring.