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The purpose of this paper is to discuss three potential contributions from implementation science that can help clinicians and researchers to design and evaluate more effective integrated care programmes for older people with frailty.

This viewpoint paper focuses on three contributions: stakeholder engagement, using implementation science frameworks, and assessment of implementation strategies and outcomes.

Stakeholder engagement enhances the acceptability of interventions to recipients and providers and improves reach and sustainability. Implementation science frameworks assess provider, recipient and wider context factors enabling and hindering implementation, and guide selection and tailoring of appropriate implementation strategies. The assessment of implementation strategies and outcomes enables the evaluation of the effectiveness and implementation of integrated care programmes for this population.

Implementation science provides a systematic way to think about why integrated care programmes for older people with frailty are not implemented successfully. The field has an evidence base, including how to tailor implementation science strategies to the local setting, and assess implementation outcomes to provide clinicians and researchers with an understanding of how their programme is working. The authors draw out implications for policy, practice and future research.

Different models to deliver integrated care to support older people with frailty exist, but it is not known which is most effective, for which individuals and in which clinical or psychosocial circumstances. Implementation science can play a valuable role in designing and evaluating more effective integrated care programmes for this population.

Older people living in nursing homes have complex care needs and frequently need specialists’ advice and support that can be challenging to deliver in a rural setting. The aim of this paper is to describe a model of integrated care in a rural area supported by a nurse case manager.

A real-world evidence study of people living in Ribes de Freser nursing home, was conducted between specific timeframes in 2019 and 2022, comparing the casemix and outcomes of a traditional care model with the integrated interdisciplinary model.

The integrated care model led to a significant reduction in transfers to the emergency department, hospitalisations, outpatient medical visits and a reduction in the number of medicines. In addition, the number of residents receiving end-of-life care at the nursing home showed a substantial increase.

This case study contributes valuable evidence supporting the implementation of an integrated model of nurse case manager support in nursing homes, particularly in the rural contexts, where access to specialist medical staff may be limited. The findings highlight the potential benefits of person-centred integrated care for older adults, addressing their complex needs and improving end-of-life care in nursing home settings.