Community-Based Integrated Care Intervention for Older Adults Through China's Family Doctor System

INTERVENTION: Full‐intervention group:1. Alert system: caregiver responses in the monthly questionnaire and prespecified triggers in quarterly assessments generate automatic notifications to the family doctor. Suicidal or self‐harm risk triggers immediate voice‐call and text‐message alerts; other concerns, including wandering, choking, delirium, severe pain, falls, emergency visits or hospitalization, and marked health deterioration, generate a summary card in the family doctor app. 2. Regular assessment and targeted family doctor guidance: trained assessors conduct home visits at months 3, 6, and 9 using a standardized WHO ICOPE‐based assessment of cognition, locomotion, vitality/nutrition, psychological capacity, and sensory capacity. The system generates traffic‐light results and matches them with predefined guidance. Results are explained and printed for the older adult and caregiver and sent to the family doctor app. 3. In‐depth face‐to‐face follow‐up: during clinic or home visits, the family doctor reviews historical assessment records and discusses the findings with the participant. 4. Caregiver support: tailored monthly education on caregiving skills, stress management, and emergency response is delivered through WeChat; caregiver health is monitored monthly with the ZBI‐4, PHQ‐2, and GAD‐2, with graded feedback and alerts. 5. Usual family doctor services.;Caregiver‐only intervention group:Caregiver support: tailored monthly education on caregiving skills, stress management, and emergency response is delivered through WeChat; caregiver health is monitored monthly with the ZBI‐4, PHQ‐2, and GAD‐2, with graded feedback and alerts. Usual family doctor services;Control group:Usual family doctor services; CONDITION: None PRIMARY OUTCOME: Intrinsic capacity;Health‐related quality of life (EQ‐5D); SECONDARY OUTCOME: Self‐reported falls and safety events;Medication adherence;Any hospitalization;Perceived care coordination;Caregiving time;Caregiver burden;Caregiver depressive symptoms;Caregiver anxiety symptoms;Caregiver‐perceived health system support;Care satisfaction;Self‐rated health; INCLUSION CRITERIA: 1. Aged 65 years or older; 2. Not residing in an institution; 3. Having an active informal caregiver involved in daily care; 4. Meeting at least one of the following: one or more limitations in activities of daily living (ADL) or instrumental activities of daily living (IADL), or a positive cognitive screening result.