Integrated Care for Older People in Viet Nam: What WHO ICOPE 2nd Edition Means for Primary Care and Community Settings
INTEGRATED CARE & CARE TRANSITIONS
Integrated Care for Older People in Viet Nam: What WHO ICOPE 2nd Edition Means for Primary Care and Community Settings
INTEGRATED CARE & CARE TRANSITIONS
Last reviewed: October 2026
Viet Nam is aging quickly. In 2024, the country had 14.2 million people aged 60 and older, 2.8 million more than in 2019, and this number is projected to approach 18 million by 2030. As the older population grows, health and care systems will increasingly encounter people living not with one condition, but with combinations of chronic disease, changes in mobility or cognition, sensory loss, nutritional problems, social needs and greater reliance on family support.
This creates a challenge for systems organized mainly around individual diseases and separate services. An older person may receive appropriate treatment for hypertension, diabetes or heart failure and still experience declining function, difficulty managing medications, unmet rehabilitation needs or poor coordination between health services, family and community support.
The World Health Organization’s Integrated Care for Older People, or ICOPE, approach was developed to address this broader challenge. WHO formally published the second edition of its ICOPE handbook in September 2025 to help health and care workers translate evidence-based recommendations into practice in primary care, including community settings. The handbook describes practical care pathways that should be adapted to local context to identify and manage declines in intrinsic capacity, recognize social-care and support needs and develop a personalized care plan.
For Viet Nam, the phrase “adapted to local context” may be one of the most important parts of the guidance.
ICOPE is more than an assessment tool
ICOPE is sometimes understood mainly as a short assessment of an older person’s function. That misses much of its purpose.
WHO developed ICOPE as part of a wider shift toward integrated, person-centered care. The aim is not simply to identify a possible decline, but to connect that finding with an appropriate response: further evaluation where needed, interventions, personalized care planning, referral, follow-up and monitoring. WHO’s implementation framework also makes clear that successful ICOPE delivery depends on service and system readiness, including workforce, coordination, information systems and connections between health and social support.
This distinction matters because assessment without a pathway does not create integrated care. If reduced mobility, cognitive concerns or nutritional problems are identified but there is no realistic route to further assessment, intervention or follow-up, the process can end with documentation rather than better care.
The more useful question is therefore not simply whether a service can perform an ICOPE assessment. It is whether the local care system can build a reliable pathway from identification of need to an appropriate response and continued follow-up.
What is different in ICOPE 2nd edition?
The second edition retains the core philosophy of ICOPE but makes the pathway clearer and gives greater attention to what can happen closer to where older people live.
WHO now describes four steps: basic assessment and community-level interventions; in-depth assessment; development of a personalized care plan; and implementation and monitoring. Step 1 has been expanded substantially. It includes basic assessment across cognition, mobility, vitality, vision, hearing and psychological capacity, together with social support, support for caregivers and urinary incontinence. It can also include health and lifestyle advice, cardiovascular-risk screening and community-based interventions for declines in intrinsic capacity. Community stakeholders can contribute across the pathway when appropriately prepared and supported.
That change matters because the first point of contact is no longer framed only as screening followed by referral. Some useful advice and community-level action can begin immediately, while findings that require more detailed assessment move to the next step.
At the same time, ICOPE does not imply that every community setting should perform every component of the pathway. What can appropriately be delivered locally depends on workforce competency, available services, supervision, professional scope and referral capacity.
Intrinsic capacity broadens the clinical question
Much of conventional health care begins with a disease: What diagnosis does the person have, and what treatment does the guideline recommend?
ICOPE adds another perspective: what is happening to the person’s physical and mental capacities, and how is that affecting everyday life?
WHO uses the concept of intrinsic capacity to bring together domains including cognition, mobility, vitality, vision, hearing and psychological capacity. Changes in these areas can affect whether an older person remains independent, manages treatment successfully, participates in daily life or recovers after illness.
This does not replace diagnosis or evidence-based medical treatment. A person with diabetes still needs appropriate diabetes management, and someone with heart failure still needs appropriate cardiovascular care. The value of ICOPE is that it widens the view so that disease management is considered alongside function, priorities and support needs.
An antihypertensive regimen may control blood pressure well but still need review if dizziness contributes to falls and loss of mobility. A medication list may be clinically appropriate but difficult to manage because of impaired vision or cognition. An older person may have no new diagnosis while gradually losing weight, strength or social support. Integrated care asks whether those pieces are being considered together.
The four steps matter because care does not end with assessment
The four-step structure helps prevent ICOPE from becoming another one-time assessment exercise.
Step 1: Basic assessment and community-level interventions identifies possible declines in intrinsic capacity and other needs, while allowing relevant health advice and suitable community-level actions to begin. Findings that require more detailed evaluation should lead onward rather than remain isolated observations.
Step 2: In-depth assessment explores identified problems more fully, including underlying health conditions, environmental factors and care or support needs. Depending on the issue, this may require clinical assessment, rehabilitation or input from other professionals.
Step 3: Personalized care planning brings together the older person’s priorities, interventions, responsibilities and follow-up into a coherent plan rather than a collection of unrelated recommendations.
Step 4: Implementation and monitoring determines whether that plan actually translates into care: referrals need to occur, interventions need to be delivered, changing needs need to be recognized and the plan needs to be reviewed when circumstances change.
Older people’s needs are rarely static. Mobility can decline after an acute illness, cognition can fluctuate, caregiving arrangements can change and a plan that worked six months ago may no longer be realistic. Monitoring is therefore part of care, not simply an administrative follow-up step.
Why primary care and community settings matter
Many important changes in later life do not first appear during a hospital admission or specialist appointment. A family member may notice that an older person is walking more slowly. A community worker may see that someone has stopped attending activities. A primary-care clinician may recognize weight loss or difficulty managing medications. A caregiver may notice increasing confusion before it becomes an emergency.
Primary care and community settings are therefore well placed to identify change earlier and maintain continuity over time. WHO’s second-edition ICOPE materials explicitly give greater attention to community engagement and to appropriately trained community health workers and other stakeholders.
But identification only becomes integrated care when there is somewhere for identified needs to go. If reduced mobility is found, can the person access an appropriate intervention? If cognitive impairment is suspected, who performs further assessment? If vision problems are identified, is there a workable referral pathway? If a caregiver is struggling, what support is available? If clinical deterioration occurs, who is responsible for escalation?
ICOPE therefore depends as much on the interfaces between services as on the assessment itself.
Viet Nam’s policy environment has become more relevant to integrated care
Recent legal and policy changes make this discussion particularly timely.
The Law on Population No. 113/2025/QH15, effective from 1 July 2026, explicitly recognizes several forms of older-person care: self-care, care at home, community care, care in older-person care facilities and care in medical examination and treatment facilities. It also provides for support to families and for the development of volunteer networks, clubs and self-help groups involved in older-person care.
Decree No. 168/2026/NĐ-CP, also effective from 1 July 2026, provides more detailed arrangements for home and community care. It recognizes older-person care clubs and community day-care points and identifies roles for volunteers, commune health-station professionals, population collaborators, village health workers and social workers.
An important legal boundary nevertheless needs to remain clear. Under Decree 168, a community day-care point is a special model under the commune-level health station, has no separate legal-person status and does not perform medical examination or treatment activities. At the same time, the decree expressly provides for community-level activities such as care and prevention education, health promotion, early recognition of health risks, physical activity and support with activities of daily living.
ICOPE implementation in Viet Nam therefore needs to distinguish between community-based assessment, education and support that can appropriately occur close to where older people live and regulated clinical activities that must remain within the relevant professional and organizational scope. The practical issue is not to push everything into the community, but to design clear interfaces between community activity and clinical services.
Decision No. 1116/QĐ-TTg, issued in June 2026, also amended the national Program for Health Care of Older Persons to 2030. Among its updated targets are wider coverage of older-person care clubs and volunteer care teams, development of day-care models, greater geriatric capacity and expanded training for people involved in older-person care. The decision also explicitly broadens some objectives from “health care for older people” toward the wider concept of “care for older people.”
None of these measures makes ICOPE a mandatory national model. They do, however, make its underlying questions, earlier recognition of decline, community support, coordination and continuity across services, increasingly relevant.
ICOPE is now moving beyond introduction in Viet Nam
Viet Nam is not starting from zero.
In August 2023, the national population authority and WHO Viet Nam organized an ICOPE workshop in Hai Phong involving representatives from Ha Noi, Hai Phong, Hung Yen and Nghe An, alongside geriatric and older-person-care organizations.
More recently, implementation activity has become visible in Da Nang. The city approved a project to build an ICOPE model under Decision No. 2504/QĐ-UBND dated 12 November 2025, with the Fred Hollows Foundation supporting the project. By the first half of 2026, the Department of Health reported training and capacity-building activities, community implementation and work on case-management arrangements. Hòa Vàng
On 29 September 2026, the Da Nang Department of Health reviewed progress of the community pilot in Son Tra with the local medical center, ward health station, local government, project team and the Fred Hollows Foundation. This is important because it shows that ICOPE in Viet Nam has moved beyond introductory discussion into real-world implementation in at least one current local project.
The evidence should still be interpreted cautiously. Local implementation activity does not yet establish national effectiveness, sustainability or readiness for broad scale-up. What it does provide is an opportunity to generate implementation learning: which pathways work, where referrals fail, what workforce and coordination are required, how much additional workload is created and how older people and caregivers experience the model.
International evidence is encouraging, but implementation remains undermeasured
A systematic scoping review published in 2026 identified 181 studies across 26 countries examining integrated care for older adults in primary health care. Most interventions were multidisciplinary, and common components included care coordination or personalized care planning, physical activity, health education and psychosocial support. Around 88% of studies reported at least one positive outcome.
But the same review also exposed an important weakness in the evidence base. Implementation outcomes were much less consistently examined: acceptability was assessed in 21% of studies, feasibility in 19% and fidelity in only 9%. Evidence was also dominated by high-income countries, with relatively limited representation from low- and middle-income settings.
For Viet Nam, that distinction matters. Evidence that an integrated-care intervention produced benefits somewhere else does not tell us whether the same pathway can be delivered reliably within Vietnamese primary care and community services.
Implementation is therefore not something that happens after the clinical model has been chosen. Implementation is part of the intervention itself.
Start with a pathway that can actually work
ICOPE contains many useful components, but broad implementation requires referral networks, multidisciplinary support, workforce capacity, information flows and services capable of responding when needs are identified.
For an initial implementation effort, a focused local pilot may therefore be more informative than attempting a broad rollout. One approach could be to define an appropriate local population, map existing services and referral capacity, introduce the ICOPE basic assessment and suitable first-contact actions, establish clear criteria for in-depth assessment and referral, develop personalized care plans for people with identified needs and monitor whether planned actions actually occur.
The target population should be determined locally rather than treated as an ICOPE requirement. Depending on the purpose of a project, an organization might focus on people with recent functional change, multiple chronic conditions, a recent hospital transition or other markers of more complex need.
Success should not be measured primarily by how many assessment forms were completed. More meaningful questions are whether identified needs led to appropriate action, whether referrals were completed, whether responsibilities were clear, whether caregivers received the support assumed by the care plan and whether older people experienced more coherent care.
A smaller pathway that works reliably can generate more useful learning than a comprehensive model that exists mainly on paper.
Assessment capacity and service capacity need to grow together
Training people to perform a basic assessment may be relatively straightforward. Building the capacity to respond to what that assessment reveals is harder.
If many older people are identified with reduced mobility but appropriate rehabilitation or exercise support is difficult to access, the bottleneck is not assessment. If cognitive concerns are recognized but there is no practical pathway for further evaluation or caregiver support, the pathway remains incomplete. If nutritional problems are identified but nobody has responsibility for follow-up, assessment becomes documentation rather than care.
Before introducing ICOPE more broadly, organizations therefore need to understand both what needs they are able to identify and what responses are realistically available when those needs are found. Service gaps should be made visible in the implementation design rather than hidden behind assessment-completion rates.
Coordination has to belong to someone
Integrated care can remain fragmented even when every professional involved is doing reasonable work.
An older person may receive recommendations from a physician, nurse, rehabilitation professional, pharmacist and community worker while family members manage much of the day-to-day care. Each recommendation can make sense individually and still become confusing, contradictory or impossible to implement when combined.
A personalized care plan therefore needs more than a document. It needs clarity about who coordinates, who follows unresolved problems, who knows whether referrals were completed and who reassesses the plan when circumstances change.
The coordinating role does not need to belong to the same profession in every setting. Local workforce and service arrangements will differ. What matters is that coordination is explicit rather than assumed.
Caregiver and social realities belong inside the plan
ICOPE 2nd edition gives greater visibility to social-care and support needs and to caregiver support.
This is especially relevant in Viet Nam, where families continue to play a substantial role in supporting older people. A care plan may depend on a spouse or adult child managing medication, meals, transportation, appointments or daily activities. If that person lacks the time, skills, physical capacity or financial resources assumed by the plan, clinically appropriate recommendations may still fail in practice.
Integrated care therefore needs to understand not only what the older person needs, but what support is realistically available around them. This does not mean the health system can solve every social problem. It means social and caregiver realities should be visible when care is designed, rather than discovered only after the plan breaks down.
Information should support care, not create another reporting system
ICOPE implementation also creates a practical information challenge.
If an assessment identifies reduced cognition, mobility or vitality, those findings need to remain visible to people involved in subsequent care. If a referral is made, its completion should be trackable. If the care plan changes, relevant professionals and, where appropriate, the older person and caregiver, need access to the updated information.
A sophisticated digital platform is not necessarily required at the beginning. A pilot can work with relatively simple information systems if they are reliable. What is more problematic is creating a separate ICOPE form whose information never becomes part of routine decision-making.
A useful design principle is therefore to collect information because it changes a care decision, action or follow-up, not simply because a framework contains a field for it.
Measurement should tell us whether the pathway worked
An ICOPE implementation project should measure more than the number of older people assessed.
At the process level, useful measures may include completion of basic assessment, the proportion of identified needs receiving appropriate further assessment, personalized care-plan completion, referral completion and follow-up. At the implementation level, feasibility, staff and older-person acceptability, fidelity to the intended pathway, workforce time, implementation barriers and reasons why planned care could not be completed are particularly important. These are exactly the kinds of outcomes that the 2026 international review found were frequently undermeasured.
At the person level, appropriate outcomes will depend on the population and follow-up period but may include maintenance or change in mobility and other aspects of intrinsic capacity, experience of care, caregiver experience and, where relevant, health-service use.
A pilot does not need dozens of indicators. A small set of measures should help answer three practical questions: Did we identify meaningful needs? Did the pathway respond to them? Did care become more coherent or useful for the older person?
ICOPE should strengthen the continuum, not become another silo
ICOPE is designed primarily for primary care, including community settings, but older people move repeatedly across organizational boundaries.
Someone may return home after hospitalization with reduced mobility and medication changes. Another person may later require long-term support. A community assessment may identify a problem requiring specialist or hospital evaluation, while a hospital discharge can create new needs that primary and community services must follow.
ICOPE is therefore most useful when it strengthens connections across hospital care, care transitions, primary care, home and community services, and long-term care, rather than becoming a separate “ICOPE service” sitting beside existing systems.
The important question is not where ICOPE belongs institutionally. It is whether its person-centered assessment, care-planning and monitoring logic can make the existing continuum more connected.
ICOPE is a framework to adapt, not a model to copy
WHO is explicit that ICOPE pathways should be adapted to local context. Successful implementation should therefore not be judged by how faithfully a Vietnamese service reproduces every detail of an international handbook.
A more meaningful test is whether the adapted pathway preserves its essential logic: identify meaningful changes and support needs, assess them appropriately, develop a person-centered plan, connect people with suitable interventions and monitor what happens afterward.
Adaptation still requires discipline. Simplifying a pathway because some services are unavailable may be realistic, but those gaps should be documented. Expanding community roles may improve access, but training, supervision and legal scope need to be appropriate. Adding assessments can improve understanding, but only if services have a realistic response to what they find.
Adaptation should therefore mean making the pathway workable without losing accountability for what it is intended to achieve.
What Viet Nam can do next
Viet Nam now has several ingredients that did not exist together only a few years ago: a stronger legal basis for home and community care, practical ICOPE implementation experience, a second-edition WHO handbook, an active local project in Da Nang and a rapidly growing older population.
The next step does not have to be national scale-up. A stronger approach would be to learn systematically from real implementation: understand existing workflows and referral capacity, adapt the pathway with local professionals and older people, prepare the workforce, establish a manageable set of measures and examine whether care can be delivered reliably over time.
That learning should include not only clinical or functional outcomes, but also implementation questions. Which referrals were unavailable? Which responsibilities were unclear? How much workforce time was required? Which components could be incorporated into routine primary care? Where did community and clinical responsibilities meet successfully, and where did they not? What did older people and caregivers find useful or burdensome?
Global guidance is already available. What Viet Nam increasingly needs is local implementation evidence and learning.
ICOPE 2nd edition offers a useful structure for that work, but its value will not come from adopting the ICOPE name or increasing the number of assessments completed. Its value will come from whether primary-care and community services can use its principles to make care more coordinated, person-centered and responsive to changing needs.
For Viet Nam, the most useful question is therefore not simply whether ICOPE should be adopted. It is how the strongest elements of ICOPE can be adapted, connected to existing services and evaluated carefully enough to build integrated care pathways that actually work for older people in Vietnamese primary-care and community settings.
That is ultimately an implementation question, and a quality-of-care question.
References
World Health Organization. Integrated Care for Older People (ICOPE): Guidance for Person-Centred Assessment and Pathways in Primary Care. 2nd ed. Geneva: WHO; 2025. World Health Organization
World Health Organization. Integrated Care for Older People (ICOPE) Implementation Framework: Guidance for Systems and Services. Geneva: WHO; 2019.
World Health Organization. ICOPE Training Programme. World Health Organization
Sun M, Liu J, Yi M, et al. Implementing integrated care for older adults in primary health care: A systematic scoping review. International Journal of Nursing Studies. 2026;176:105342. PubMed
General Statistics Office of Viet Nam. Press Release: Results of the 2024 Mid-Term Population and Housing Census. 2025.
National Assembly of Viet Nam. Law on Population No. 113/2025/QH15. 10 December 2025; effective 1 July 2026. Chinh Phu
Government of Viet Nam. Decree No. 168/2026/NĐ-CP detailing provisions and measures for implementation of the Law on Population. 15 May 2026; effective 1 July 2026. Chinh Phu
Prime Minister of Viet Nam. Decision No. 1116/QĐ-TTg amending Decision No. 1579/QĐ-TTg approving the Program for Health Care of Older Persons to 2030. 22 June 2026. Chinh Phu
Population authority, Ministry of Health, and WHO Viet Nam. Workshop introducing Integrated Care for Older People (ICOPE). Hai Phong, 7–8 August 2023. Vietnam Tourism
Da Nang People’s Committee / Da Nang Department of Health. Project to develop an Integrated Care for Older People (ICOPE) model, approved under Decision No. 2504/QĐ-UBND, 12 November 2025. Hòa Vàng
Da Nang Department of Health. Mid-year review of the ICOPE project, first six months of 2026. 21 June 2026. Trang thông tin điện tử Sở Y tế
Da Nang Department of Health. Review of progress of the community ICOPE pilot in Son Tra. 30 September 2026. Hòa Vàng