Prior to the start of the program, a consensus process was developed with different national and international experts in aging and complex interventions, establishing best practices to implement complex community interventions to prevent or delay disability (doi: 10.1016/j.ejim.2018.07.022). These included many of the aforementioned implementation principles and worked as a manual for knowledge translation during the implementation of +AGILBcn and its current scale-up phase. In general, translating evidence into practice often fails due to the complexity of replicating and adapting studies built on selected populations and rigid intervention schemes to real-life settings, where populations and conditions are heterogeneous and resources are limited. Therefore, user participation in a co-design process for adapting available evidence is mandatory. Engaging different actors to overcome the fragmentation of the healthcare system is another big challenge we aimed to address. +AGILBcn proposed integrating primary and geriatric care from the beginning, working as a team with older adults, including available community resources. This aspect has been crucial in identifying older adults in situations of vulnerability and their needs and designing a tailored intervention plan. Other challenges included designing a multidimensional intervention close to participants' homes and person-centeredness (adapted to personal preferences but based on the comprehensive geriatric assessment results). As mentioned, we are currently scaling up +AGILBcn in three more neighborhoods, with the co-design phase underway.

Older people with chronic health conditions or disability, Older people with vulnerabilities

Health, Urban development

Government, Civil Society Organization, Older People's Association, Health Care, Social Care

Older people were part of the process at multiple or all stages

+AGILBcn stems from a strategic alliance between the principal public providers of primary care in Barcelona (Institut Català de la Salut, Àmbit d'Atenció Primària de Barcelona) and intermediate care, geriatrics and palliative care in Catalonia (Parc Sanitari Pere Virgili). The program started in the primary care center of Bordeta-Magòria (Barcelona, Spain), which provides healthcare services to 32,340 citizens (20% aged ≥65 years, 6.9%≥80 years). The geriatric team, including a geriatrician and a physiotherapist, visits the primary care center 1 day/week to assess older adults with low intrinsic capacity as previously identified by the primary care team (i.e., family physicians, nurses, and social workers). Once the co-designed intervention has ended, the program fosters the subsequent continuation of physical activity through existing community resources, such as a co-designed program with a nearby civic center in which group exercise sessions are initially performed under the supervision of a fitness trainer but progressively shifted toward self-practice. Moreover, we involved volunteer organizations offering specific programs to revert loneliness and a healthcare faculty from a private university to reinforce the exercise intervention. We are now adapting the program for its scale-up in Barcelona's three other primary care centers. For this, first, we are conducting a co-creation process involving all stakeholders (healthcare and social care professionals, policy-makers and administrators, older adult associations, and civil society organizations). Moreover, we are collaborating with urban planners to analyze the built environment in terms of age-friendliness and its impact on health, well-being and quality of life in older adults.

+AGILBcn has had a positive impact by improving intrinsic capacity in older adults, enhancing daily clinical practice with an integrated care approach, and boosting new collaborations among community organizations. First, the program has been shown to improve physical performance in older adults at three months (doi: 10.1007/s12603-019-1244-4), maintaining the results at six months, also in individuals with cognitive impairment or lower intrinsic capacity; which represents a significant achievement, considering the participant's age at enrollment. Older adults expressed high confidence and motivation to practice physical activity following the intervention advices; this was evident during the COVID-19 lockdown when 22.5% of former +AGILBcn participants reported following personalized physical activity recommendations derived from the program (doi: 10.3390/ijerph18020808). According to participant's feedback (surveys and interviews), +AGILBcn boosted their motivation, engagement, and "re-activation" post-lockdown, encouraging them to get out of their houses, restart an active life and reconnect with the community. Second, a spontaneous change occurred in the healthcare area, shifting from a fragmented, classical approach toward a new integrated care model. +AGILBcn now forms part of the usual care in the primary care center. In addition, +AGILBcn has triggered a "domino effect" on older adult care in the corresponding neighborhood, thanks to the transfer of knowledge between geriatric and primary care staff through working together and conducting lectures on demand. The program has also impacted the community by building a network and connecting and engaging available community resources, sometimes by rerouting them in novel ways (e.g. "Health Challenges" civic center activity).

+AGILBcn's target population has a relatively high functional capacity but exhibits a high comorbidity profile, increasing the likelihood of clinical decompensation and/or missed exercise sessions or follow-up visits. We addressed this issue by maximizing the flexibility needed for rescheduling sessions and adapting the intervention to the participant's clinical situation and functional capacity. Engaging older adults in changing lifestyle habits, especially in terms of physical activity, was challenging due to their previous lack of knowledge on what activities perform and how, as well as their resistance or fear of starting. Offering a personalized, tailored program featuring functional exercises supervised by a physiotherapist was crucial. To empower them and foster adherence, we: a) delegated leadership of part of the final group sessions to participants; b) recommended personalized exercises as "homework"; c) guided participants to existing community resources for continuing; d) engaged the primary care staff, to "prescribed" +AGILBcn; and e) boosted motivation by encouraging social interaction and support among participants. After three months, many participants wanted to continue the physiotherapist's intervention, which was impossible, as it was the turn of newly recruited participants. +AGILBcn design anticipated this need, reinforcing the participant’s empowerment and program sustainability. Specifically, co-designed, associated activities on existing community resources were introduced to guarantee continuing, while sharing knowledge about specific exercises and complementary digital tools helped participants to move toward self-practice. The strict COVID-19 lockdown forced us to suspend in-person activities. However, we re-designed and adapted strategies for continuing exercise sessions through digital solutions for home-based sessions.

Lesson 1: User participation through co-design is key to incorporating their needs and preferences and maximizing adherence (>75% of participants completed the program). Available RCTs had featured a higher frequency of in-person group exercise, which did not fit well with older adults' organization (e.g. care of grandchildren or leisure activities). For that reason, we agreed to adjust and complement the intervention with digital solutions. Also, while a specific community resource (e.g. a nearby civic center) may be available in a particular area, it may not be in a different area; while another resource may be included. Thus, co-design must be repeated during scale-up in each new site. Lesson 2: Flexible inclusion criteria and an individualized intervention are necessary. +AGILBcn inclusion criteria were co-designed by primary care and geriatric teams. Primary care professionals selected the Gerontopôle Frailty Screening Tool to identify possible candidates. Flexibility also allows for occasionally including individuals with lower intrinsic capacity, higher disability, or younger participants. Unlike a rigid clinical trial, this issue is relevant in a real-life program such as +AGILBcn. Lesson 3: Harnessing existing community resources (health and social care, third sector community resources) is pivotal to offering individualized solutions and guaranteeing program sustainability. As previously explained, +AGILBcn has progressively integrated healthcare and social professionals and professionals from the nearby civic center and volunteer organizations. Engaging community organizations and infrastructures has resulted in a 'win-win' situation, generating a positive impact on the program (i.e. adherence and sustainability) and the community (i.e. networking and new collaborative initiatives).

The Decade initiative has helped us to raise awareness and increase sensitivity among the general population, healthcare professionals, public authorities and decision-makers about the importance of working together to promote healthy ageing. The visibility of this issue helped us obtain three grants from the Barcelona City Council, two of these aimed at adapting and scaling up the program in three other Basic Health Areas (BHAs) in Barcelona with different socioeconomic characteristics. The third is to analyse how the urban/built environment can influence physical activity patterns, well-being and quality of life in program participants. This work was particularly stimulated by the first action item of the Decade. Additionally, the sensitivity generated by the Decade initiative has also helped to generate and raise interest, motivation and implication among all stakeholders involved in the implementation process. Even though +AGILBcn precedes the publication of the Integrated Care for Older People (ICOPE) guidelines, it is proposed as a tailored, multimodal intervention aligned with the ICOPE guidelines. Moreover, the ICOPE recommendations have also reinforced our program.