Background: Community-centred care integration for older adults is a cornerstone of the WHO's Integrated Care for Older People (ICOPE) implementation framework. Realising the potential of care integration for older people requires cohesive coordination of services and interprofessional collaboration (IPC) within and across teams. There is a gap in research evidence to understand how IPC can be fostered and sustained within team-based community care integration for older people. We report on a realist evidence synthesis to identify the contextual influences and mechanisms that support IPC in interprofessional community care teams for older people.

Methods: The three phases of the realist synthesis included an exploratory scoping of research evidence and consultation with four local stakeholder groups to produce initial programme theories. The second phase involved systematic retrieval and synthesis of evidence, including peer-reviewed published empirical studies and grey literature recommended by an expert panel. The third phase involved the development of refined programme theory with stakeholder validation. The stakeholder cohorts included representatives of older people and caregivers, healthcare professionals and operational managers of community specialist older person teams, national policymakers, and programme managers.

Results: The resource and reasoning mechanisms that enable contexts for IPC and their associated outcomes are identified within seven programme theory areas: (1) professional identity and growth, (2) information sharing and care coordination across boundaries, (3) effective operational and clinical governance, (4) developing a team learning culture, (5) meaningful inclusion of older people and caregivers, (6) quality improvement and programme development, (7) workforce planning and retention.

Conclusions: The results provide policymakers and clinicians with evidence-based programme theory that will catalyse critical dialogue on IPC implementation. This programme theory informs the prioritisation of resources to enable favourable contexts for successful IPC intervention development and implementation. This research complements and expands the work presented in the WHO ICOPE implementation framework. We encourage local realist application and evaluation of the programme theory within varying health system contexts.

Keywords: Healthcare teams; Integrated care; Interdisciplinary; Interprofessional collaboration; Older person; Realist synthesis.

© 2025. The Author(s).

背景：社区中心化的老年人照护整合是世界卫生组织（WHO）综合老年人照护实施框架（ICOPE）的核心。实现老年人照护整合的潜力需要服务之间以及团队内部和跨团队之间的协调合作。然而，关于如何促进和发展基于团队的社区照护中的跨专业协作(IPC)的研究证据不足。我们报告了一项现实主义证据综述的结果，以识别支持老年人社区照护团队IPC的相关背景因素和机制。

方法：本研究的三个阶段包括对研究证据进行探索性概述，并与四个地方利益相关者群体协商，产生初始计划理论。第二阶段涉及系统地检索和综合证据，包括同行评审发表的经验研究文献以及由专家小组推荐的灰色文献。第三阶段则涉及在利益相关者的验证下发展精炼后的计划理论。利益相关者团队包括老年人及其照顾者、医疗保健专业人员及社区专科老年人团队的运营经理、国家政策制定者以及项目管理者。

结果：七个计划理论领域中的资源和推理机制被识别为支持IPC的背景因素，以及其相关的成果：（1）职业认同与成长；（2）边界内外的信息共享及护理协调；（3）有效的运营和临床治理；（4）培养团队学习文化；（5）老年人及其照顾者的有意义参与；（6）质量改进和项目发展；（7）劳动力规划与保留。

结论：本研究的结果为政策制定者和临床医生提供了基于证据的计划理论，以促进关于IPC实施的关键对话。此计划理论指导了对资源的优先配置，以便在有利的背景下开发并实施成功的IPC干预措施。这项研究补充和完善了WHO ICOPE实施框架的工作。我们鼓励在不同的卫生系统背景中应用和评估该计划理论。

关键词：医疗团队；综合照护；跨学科；跨专业协作；老年人；现实主义综述。

© 2025. The Author(s).