• Adults aged 65 and above (55 and above for Indigenous populations).

• Individuals who are long-term bedridden or whose interval since the previous assessment is less than one year are excluded.

In 2025, Taiwan officially entered a super-aged society, with over 20% of its population aged 65 and above. To address the challenges of population aging, the Health Promotion Administration launched the Integrated Care for Older People (ICOPE) initiative in 2021. This program aims to enhance the self-care abilities of older adults through early functional assessments and integrated care, promoting healthy and aging-in-place lifestyles.

HsinChu Mackay Memorial Hospital responded proactively from the start, incorporating ICOPE into outpatient, inpatient, rehabilitation, and long-term care services. A cross-departmental collaboration mechanism was established to ensure that older patients receive timely assessments and follow-up during every hospital visit, enabling early detection and prompt intervention.

The hospital also set up a dedicated ICOPE outpatient clinic, where trained nurses conduct assessments and provide health guidance. These nurses help older adults adopt healthier lifestyles and actively communicate care suggestions with family members. Beyond the hospital, the ICOPE team engages in community outreach by organizing health education sessions and on-site evaluations in local groups, churches, and senior centers.

Guided by the principle of “Love Others as Ourselves” and caring for the vulnerable, the ICOPE team is committed to building a compassionate and people-centered care system, fully preparing for the needs of an aging society.

• Strengthen policy implementation through vertical integration, and promote interdepartmental communication through horizontal integration, jointly advancing program goals and development.

• Expand outward from hospitals as the core, with ICOPE healthcare teams entering communities to extend medical care and health promotion resources beyond hospital settings.

• Innovative designs integrate diverse approaches to enhance assessment and outreach activities, including self-produced graded exercise promotion videos for older adults, the use of board games, and AI-enhanced themed promotions, such as ACP combined with ICOPE.

• Service volume in 2021: 2,454 individuals

• Service volume in 2022: 1,691 individuals (self-assessment) and 3,003 individuals (hospital-based assessment)

• Service volume in 2023: 2,095 individuals

• Service volume in 2024: 2,529 individuals

• Service volume in 2025: 2,095 individuals

• More than 2,000 cases are enrolled each year.

• Service target achievement rate: 100%.

• Community outreach coverage rate: 13.9%, with a goal of adding three new neighborhoods each year to progressively increase community coverage.

• An average of at least 17 health education lectures are held each year, reaching an average of over 1,000 participants annually.

• Reassessment rate for older adults’ functional assessment services: 100%.

• Follow-up completion rate for older adults’ functional assessment services: over 90%.

• Post-test rate for older adults’ functional assessment services: over 80%.

• At least 2 exchange meetings and case discussion sessions are held each year.

• Public outreach activities achieved 100% satisfaction in satisfaction surveys.

• Staff exchange meetings achieved 100% satisfaction in satisfaction surveys.

• Domestic Academic Paper Publication

• Oral Presentation at 2021 Taiwan Joint Conference in Healthcare : Strategies and Outcome Analysis for Implementing Integrated Health Assessments for Older Adults.

• Poster Presentation at 2021 Taiwan Joint Conference in Healthcare : Planning Proposal for Establishing a Dedicated Integrated Care for Older People (ICOPE) Clinic.(Taiwan Joint Conference in Healthcare )

• Poster Presentation at 2022 Taiwan Association of Gerontology and Geriatrics :Implementation of the integrated care of Older People (ICOPE) in the Hospital-Hsinchu MacKay Memorial Hospital Experience.

• Poster Presentation at 2023 Taiwan Joint Conference in Healthcare : Sharing Strategies for Integrated Implementation of ICOPE Operations.

• Strengthen team-based collaboration through vertical and horizontal integration, establish cross-unit referral and support mechanisms, and integrate hospital and community settings to deliver ICOPE services, thereby maximizing resource utilization and promoting healthy aging among older adults.

• Utilize information systems and digital tools to enhance data management efficiency and ensure the completeness and continuity of assessment services.

• Seize opportunities during large-scale in-hospital health promotion events to conduct pop-up promotions of the ICOPE concept, increasing awareness and participation among hospital staff, community partners, and the general public.