Korea faces a super-aged society. Considering comorbid multiple diseases of the elderly, the integrated medical and social care are required. However, healthcare system of Korea is fragmented and is not centered on senior friendly care.

Therefore, this study aimed to a) identify frailty among the elderly living in a community, b) explore frailty prevention and management schemes in community, c) explore hospital-based senior friendly healthcare service delivery models, and d) review policies and regulations related to the senior friendly healthcare services.

For this purpose, we reviewed existing literature and conducted site visits(Taiwan, Hongkong and Singapore) to understand their senior friendly healthcare services. In addition, we conducted a survey and individual interviews to examine the frailty status of the elderly in Chungnam province. We also conducted two pilot demonstration project. First pilot project is to test care for prevention and management of frailty in local community. Second pilot project is to test integrated medical services provision for the elderly with hip fractures, spine disease, cancer and elderly patients who need cardiac rehabilit -ation in Yonsei Severance Hospital. We also conducted expert opinion survey to draw policies. Lastly, we held an international symposium to share experiences on healthcare policies for the elderly.

Findings of this study highlights the importance of frailty prevention and management and senior friendly healthcare services in both community and medical settings. This study also draws attention to develop concrete policies to strengthen the integrated healthcare services for the elderly.

Finally, this study proposed policy tasks. Main tasks are to 1) establish new central governance system, 2) rebuild strategy of senior-friendly healthcare services, 3) expand manpower and strengthen the capacity of healthcare workers in medical institution and community 4) conduct research and develop evidence based guideline and programs, 5) establish phased plan for managing frailty according to frailty status and build community care team, 6) develop patient centered medical home and help primary physician to coordinate services, 7) establish senior friendly hospital system, 8) implement pilot projects according to the level of community resources, 9) restructure payment system for senior friendly healthcare. 

Abstract ················································································································1

Part 1: Research Overview

Chapter 1. Introduction ·······················································································19

A. Research Background and Purpose ················································································21

B. Research Scope and Methods ········································································23

Part 2: Community Aging and Its Management

Chapter 1. Introduction ·······················································································29

A. Reearch Background and Purpose ················································································31

B. Research Scope and Methods ················································································32

Chapter 2. Community Aging and Its Management ···················································33

A. Survey Overview and Purpose ················································································35

B. Health Status of the Aged in Communities ···················································43

C. Local Users' Experience of Health and Social Care ···············57

D. Chapter Conclusion ·······································································································71

Chapter 3. Overseas Frailty Prevention and Management Programs ·····································75

A. What is Fraility Prevention and Management ·······························································77

B. Overseas Frailty Prevention and Management Programs ·······························································82

Chapter 4. Current State of Community Frailty Prevention and Management Programs ···········91

A. Current State of Local Frailty Related Programs ·································································93

B. Types and Problems of Current Frailty Management Services: Focusing on Home Care Programs ············100

Chapter 5. Community Based Integrated Frailty Management Pilot Project ·························107

A. Overview of the Project: Research Background ···································································109

B. Theoretical Model Development: Process and Results ······················································111

C. Pilot Project Purpose and Methods ·······································································123

D. Progress and Results of the Pilot Project ···························································125

E. Chapter Conclusion ·····································································································168

Chapter 6. Part 2 Conclusion: Community Frailty Management Model and Its Implications ·························171

A. Principles and Reality of Community Frailty Management ··············································173

B. The Community Frailty Management Model and Policy Suggestions ····························································175

Part 3: Senior Friendly Health Care Services

Chapter 1. Introduction ·····················································································181

A. Research Background and Purpose ···········································································183

B. Research Scope and Methods ··············································································184

Chapter 2. Overseas Case Study ·····································································187

A. Senior Friendly Hospitals ····················································································189

B. Transitional Care ·························································································205

C. Primary Home Care ···············································································208

Chapter 3. Senior Friendly Health Care Service Pilot Project ···············215

A. Project Overview ······················································································217

B. Project Design and Measurement ·······························································218

C. Project Outcomes ······················································································221

D. Senior Friendly Hospitals: Challenges Ahead ···························································272

Chapter 4. Expert Opinion Survey on the Senior Friendly Health Care Services ···279

A. Survey Overview ····························································································281

B. Senior Friendly Hospital Services ····································································283

C. Senior Friendly Transitional Health Care Services ··························································290

D. Primary Home Care ···············································································297

E. Policies and Regulations Related to Senior Friendly Health Care Services ··································302

Chapter 5. Part Conclusion: Policy Implications ···309

A. Research Results and Their Implications ··································································311

Part 4: Policy Suggestions

Chapter 1. Policy Suggestions for the Development of Senior Friendly Health Care Services ···········319

References ···························································································327

Appendices ··································································································347