Community-Empowerment and Environmental Enrichment-based Co-management (CEEEC) Model and Mechanisms for Improving Health of Older Stroke Patients With Multimorbidity

Assessment of intrinsic capacity using the World Health Organization Integrated Care for Older People (WHO ICOPE) framework.

The Short Physical Performance Battery (SPPB) is a validated, performance-based tool designed to assess lower extremity function in older adults. It consists of three components: a balance test, a gait speed test, and a chair stand test. Each component is scored on a scale from 0 to 4, with a total score ranging from 0 (worst performance) to 12 (best performance).

Cognitive function will be assessed using the Montreal Cognitive Assessment (MoCA), a widely validated screening tool for mild cognitive impairment. The MoCA evaluates multiple cognitive domains, including attention and concentration, executive functions, memory, language, visuoconstructional skills, conceptual thinking, calculations, and orientation.

The MoCA score ranges from 0 to 30, with higher scores indicating better cognitive function. A score of 26 or above is generally considered within the normal range.

Assessments will be conducted at baseline and at regular intervals across the 24-month study period to track changes over time.

Psychological well-being will be assessed using the Cornell Scale for Depression in Dementia (CSDD), a clinician-administered instrument specifically designed to assess signs of depression in individuals with cognitive impairment, including those with dementia. The CSDD incorporates information from both patient interviews and caregiver reports to increase the reliability of the assessment.

The scale includes 19 items, each scored from 0 (absent) to 2 (severe), resulting in a total score ranging from 0 to 38. Higher scores indicate more severe depressive symptoms, reflecting poorer psychological well-being. A score of ≥12 suggests probable major depression, while scores between 8-11 indicate possible depression.

CSDD assessments will be performed at baseline and repeated at regular intervals throughout the 24-month study period.

Vitality will be assessed using the Mini Nutritional Assessment (MNA), a validated screening and assessment tool designed to identify older adults at risk of malnutrition or undernutrition, which are closely associated with reduced physical vitality and frailty.

The full MNA consists of 18 items, producing a total score ranging from 0 to 30. Higher scores indicate better nutritional status, reflecting greater vitality and overall health.

A score of 24-30 indicates normal nutritional status. Scores 17-23.5 suggest risk of malnutrition. Scores <17 indicate malnutrition. The MNA will be administered at baseline and at regular follow-ups over the 24-month study period to monitor changes in patients' nutritional status and associated vitality.

measured using the 4-item Morisky Green Levine Scale-4 (MMAS-4). The 4-item Morisky Green Levine Medication Adherence Scale (MMAS-4), is a validated self-reported questionnaire that evaluates patients' behaviors related to medication-taking. The scale consists of 4 yes/no questions, with each "yes" answer scored as 1 and each "no" as 0. The total score ranges from 0 to 4, with higher scores indicating lower adherence.

A score of 0 indicates high adherence. 1-2 indicates medium adherence. 3-4 indicates low adherence.

Measurement of physical activity levels in metabolic equivalent of task (MET) minutes per week.

Change in the systolic blood pressure.

change in weight

change in height

participants' neck circumference

Participants' waist circumference

measured by timed-up-and-go test, a simple and quick functional mobility test that requires the participants to stand up, walk 3 meters, turn, walk back, and sit down

The Geriatric Depression Scale - 15 item version (GDS-15) is a self-report questionnaire designed to screen for depression in older adults. It contains 15 yes/no questions that assess mood, motivation, energy levels, and outlook on life over the past week. Scores range from 0 to 15, with higher scores indicating more severe depressive symptoms, thus reflecting a worse outcome. Each depressive answer is scored as 1 point, and the total score is the sum of these points. Commonly used cut-off points are: 0-4 (no depression), 5-8 (mild depression), 9-11 (moderate depression), and 12-15 (severe depression).

measured using EuroQol-5 Dimensions-5L (EQ5D-5L). EQ-5D-5L descriptive system comprises the following five dimensions, each describing a different aspect of health: mobility, self-care, usual activities, pain/discomfort and anxiety/depression. For each domain, the total scores range from 0 (indicating no problem) to 5 (indicating unable to/extreme problems). In addition, the participants were required to assess how their health is today by write a number from 0 to 100 on the numbered scale. 100 means the best health the participant can image, 0 means the worst health the participant can image.

The factors include lack of exercise, alcohol, diet, obesity, and smoking, and will be collected through questionnaire.

measured by the basic activities of daily living (ADL). The basic ADL include the following categories: Ambulating, Feeding, Dressing, Personal hygiene, Continence, and Toileting. The ADL score ranges from 0 to 12. Limitation in ADL was defined as being scored greater than 0 on ADL scales, i.e., having some or severe limitation in at least one ADL item. Higher scores mean a worse functional independence.

measured by the Lawton Instrumental Activities of Daily Living (IADL) Scale to evaluate independent living skills. The scale measures eight domains of function, including food preparation, housekeeping, laundering. The IADL score ranges from 0 to 14. Limitation in IADL was defined as being scored greater than 0 on IADL scales, i.e., having some or severe limitation in at least one IADL item. Higher scores mean a worse functional independence.

measured using modified Rankin Scale (ranged 0 (no symptom) to 5 severe disability)

Assessed by determining whether participants had additional diseases diagnosed in the hospital, excluding stroke

Grip strength (kilogram) will be estimated through the dynamometer (YuejianTM WL-1000, Nantong, China). Trained examiners will instruct people to hold the dynamometer and squeeze the handle for a few seconds. This study both measures right and left-hand grip strength twice in each hand. The grip strength will be recorded separately. If the average grip strength of both right and left hand of is all less than the criteria (man < 30 kg, woman < 20 kg), it is defined as weak grip strength.

Measured by the total number of months during the 24-month follow-up period that the patient continuously takes the prescribed medication.

The number of hospital visits (both inpatient and outpatient) will be measured during the 24-month follow-up period. This will include the total number of hospital admissions, along with any follow-up outpatient visits associated with hospital care. Unit of Measure: Number of hospital visits

The number of emergency room visits will be assessed over the 24-month period. This includes any visits to the emergency room for acute health concerns or urgent care needs.

Unit of Measure: Number of emergency room visits

The number of outpatient visits (excluding emergency room and inpatient visits) will be measured throughout the 24-month study period. This includes visits to primary care providers, specialists, and other outpatient services.

Unit of Measure: Number of outpatient visits

Presence of chronic diseases reported by participants through a structured questionnaire. Unit of Measure: Count of documented diseases

Number and type of diagnosed chronic diseases retrieved from participants' medical insurance claims data. Unit of Measure: Count of documented diseases