1. Introduction
Integrated care is an appropriate approach in the field of geriatric health due to the provision of long-term, comprehensive and quality care [1]. The ultimate goals of these cares are to increase the quality of care and the quality of life and reduce the costs imposed on health system [2]. According to the World Health Organization, integrated care is health services that are managed and delivered in a way that ensures people receive a continuum of health promotion, disease prevention, diagnosis, treatment, disease management, rehabilitation and palliative care services [3]. The important challenge of this care system is that it has been designed for sick and disabled older people, and lacks community-based health promotion services [4]. In other words, healthy older people are neglected in this approach, which contradicts the justice-oriented nature of health services [5]. This study aims to improve the quality of integrated geriatric care in comprehensive care centers.

2. Methods & Materials
This community-based participatory study was conducted in 4 stages of finding the problems, developing change programs, and implementing change programs from 2016 to 2018 with the participation of 11 healthcare providers, 54 older people and 54 family members in Shahid Motahari Comprehensive Health Center in Mashhad, Iran. This center provides services related to the first and second levels of primary health care, and provides services to different age groups based on the formation of electronic health records and service packages. Since the study was conducted in the health center environment, all health workers were included in the study. A public call was used the participation of the elderly. Participants were involved in all stages of the research including data collection, development of focus groups, and implementation of protocols. Qualitative data collection tools were interviews, focus group discussions, and field note taking, while quantitative data was collected by the SERVQUAL questionnaire [6]. The implementation problems were identified through interviews with 8 personnel and 19 older people. Main problems were: Lack of clear concept of healthy aging in personnel, lack of proper structure, and inability of personnel. The list of problems was provided to the involved group for approval. During a group discussion session, the prioritized problems were approved by the participants and the suggested solutions were received from them. Solutions were prioritized based on urgency, majority agreement, feasibility, upstream documents of aging, and readiness of research team. Through a focus group discussion, the change programs were designed in 4 areas of physical structure improvement, staff empowerment, preparation of healthy elderly care records, and home visits by participants. The change programs were implemented in the comprehensive health center for 2 years. After implementation, the data were collected through quantitative and qualitative methods and compared with the previous ones. 

3. Results
In the present study, participants were 11 comprehensive health center personnel (8 healthcare providers, 1 physician, 1 secretary, and 1 service staff) and 54 healthy elderly and their families. The mean age of healthcare providers was 32.4±2.7 years with a work experience 8.3 years. The mean age of the elderly was 64.3±3.9 years and 51.8% were male. The mean total score of service quality according to the elderly and their families in the pre-intervention stage was 63.02±9.46 and 61.83±9.05, respectively. These values reached 130.09±14.75 and 122.65±13.56 in the post-intervention stage, and this difference was statistically significant (P=0.001). Hence, the implementation of change programs could improve the quality of services provided in the comprehensive health center. In the qualitative section, the results of interviews with participants before and after implementation of the change programs showed that dissatisfaction of the elderly and families changed to their satisfaction; rule-based care changed to organized care; lack of awareness of healthy aging changed to recognizing healthy elderlies and assessing their needs; lack of education for healthy elderly changed to regular training based on the needs of the elderly; inability of personnel changed to their ability to work with healthy elderlies; and lack of communication with families changed to family participation in caring for healthy elderlies.
The results of combining quantitative and qualitative data showed that the most important factors affecting the quality of an integrated geriatric care program were: Modification of the physical and spatial structure, empowerment of personnel, and standardization of care. Thus, according to the changes, the satisfaction of healthy elderlies and their families increased in five areas of service quality including responsiveness, assurance, empathy, tangibility and reliability. These changes in the health care team can provide increased responsibility, functional independence, decision-making authority, accountability, improved inter-professional relationships, and organized care for the elderly and their families whose consequences are satisfaction, confidence and willingness to return to the health center. Based on the content analysis, a new concept of “dynamic care” was obtained whose main categories included: Standard care for the healthy elderly, creating interest and improving staff performance in working with the healthy elderly, following up on care through scheduled home visits, and providing regular geriatric health promotion programs to healthcare staff, the elderly, and families.

4. Conclusion
The dynamic care model with features such as active, participatory, continuous, comprehensive and supportive care improved the quality of geriatric care services for the healthy elderly. Improving the equipment and physical structure, empowering personnel, and standardizing care, were among the factors affecting the quality of the integrated care program in line with “healthy aging”. Providing standardized geriatric care with responsibility, authority, accountability, professional inter-personal relationships and home visits and organized training can lead to the increase in sense of confidence, trust, awareness, consultation with healthcare staff, and satisfaction in healthy seniors and their families. The findings of this study can be used for empowerment of the comprehensive health center personnel in providing geriatric care. Since working with individuals, families and groups the field of community health, should be done in the context of society and given the fact that society is the main area of providing health services, the community-based approach used in the present study can be a practical model for similar studies.

Ethical Considerations
Compliance with ethical guidelines
This study was approved by Etical Coommittee of Tarbiat Modares University (Code: IR.MODARES.REC.1395.17). All ethical principles were observed. Participants were allowed to leave the study at any time. They were aware of the research process and the confidentiality of their information.

Funding
This study eas supported by the Deputy for Research of Tarbiat Modares University.

Authors' contributions
All authors contributed equally in preparing this article.

Conflicts of interest
The authors declare no conflict of interest.