Table 1 Description of the CIE model: components and implementation information {13}

Comprehensive geriatric assessment (CGA)

Profile registration form including medical history, functional scales and service demand evaluation in social work practice

GP-rehabilitation doctor-social worker

At each CEC or at each home

At T0

At least Once Anytime needed (condition change of residents)

Individualized care planning (CP)

A written checklist form

GP-rehabilitation doctor-social worker Residents/family members/caregivers

At each CEC or at each home

Right after the CGA is done at T0

At least Once Anytime needed (condition change of residents)

Community-based rehabilitation (CBR)

Individualized, written plans with goals, timeline, and therapies

Specialists in physical and rehabilitation medicine

At each CEC or at each home

When CGA and CP are done

At least twice a week

Interdisciplinary case management (ICM)

A written checklist form

GP-rehabilitation doctor-social worker Residents/family members/caregivers Facilitated by enablement officer and coordinator team

At each CEC

When a relevant case is found

At least once a month

Care coordination (CC)

Shared information among stakeholders Coordinated action among service providers

The onsite coordinator team facilitated by enablement officer

-

The whole study period

-