Transforming Geriatric Care: A HIMSS Level 7 Model for Holistic Patient-Centered Service Delivery (® Life Concerto)

As societies age, the demand for high-quality, continuous elderly care rises. Traditional clinical care often struggles to address the multifaceted needs of older adults, particularly those requiring long-term care. The Continuity of Care Maturity Model (CoCMM) by HIMSS highlights the importance of integrated, patient-centered care, yet challenges such as fragmented communication, insufficient data integration, and lack of real-time records persist in Taiwan.

This study aimed to design, implement, and evaluate "Life Concerto," (®) an AI-enabled integrated communication and collaboration platform, to address these gaps and improve care quality and efficiency.

Life Concerto utilized a BERT-based natural language processing system for keyword and message classification, supported by expert-curated decision-support algorithms. The platform facilitated multilingual communication, real-time interaction, and structured documentation among caregivers, healthcare providers, and family members. Pilot implementation included 897 chat rooms and over 2,167 users across 35 institutions, integrating use cases for long-term care, home-based acute care, and dementia care.

Results showed a 5.5 times per week interaction frequency between patients and care teams, significantly higher than traditional care models. It also reduced dementia visit times by 66.4%, cutting administrative workload and improving data accuracy, as it enabled real-time sharing of patient conditions, vital signs, and episode records. Multilingual support, including Indonesian, Filipino, Vietnamese, and English, broke down language barriers and ensured inclusive communication for foreign caregivers.

Achieving HIMSS Continuity of Care Maturity Model Level 7, Life Concerto established a dynamic, interconnected, patient-centered care model. While adoption barriers such as training requirements and resistance to change were noted, the platform's success highlights the transformative potential of AI-driven solutions in elderly care. Future efforts should focus on seamless integration with electronic health records (EHRs) and addressing implementation challenges to promote widespread adoption and enhance holistic care delivery.