Implementing ICOPE in New Mexico: A process-oriented approach to promoting healthy aging in older adults

Abstract

The New Mexico Health Care Authority, the University of New Mexico Hospital, and the School of Medicine partnered in 2024 to implement the World Health Organization’s Independent Care for Older People (ICOPE) program. The program’s mission is to “empower New Mexico's seniors through prevention and person-centered care, enhancing health, independence, and quality of life by improving services, resources, and community support for healthy aging.”

Using the 2025 second edition of the ICOPE manual, the New Mexico ICOPE team has developed a strategic plan, an organizational structure reliant on community partnerships, a project plan, and algorithms to address the six ICOPE intrinsic capacities, as well as assessments of three key factors including urinary incontinence, social and carer support. The detailed process for algorithm development is described herein. These algorithms are the basis of the smartphone application developed to allow seniors to complete the ICOPE Basic Assessment and significant portions of the In-Depth Assessment at home. The algorithms are designed to enhance the use of community support resources and reduce the need for health care system visits when appropriate, while at the same time integrating primary care services whenever needed.

The system architecture and data and information flow are illustrated. The program's evaluation is structured according to the Practical, Robust Implementation and Sustainability Model (PRISM), used to identify the elements of implementation and effectiveness that will be measured. These include contextual factors such as institutional adoption, implementation, and maintenance of ICOPE, the program's reach, and the impact of ICOPE on patient experience of care, population health, and cost of care.

1. Introduction

New Mexico (NM) is the fifth-largest state by area in the United States (U.S), with a population that ranks 36th and a population density that ranks 47th [[1], [2], [3]]. Our state has the fifth-highest poverty rate among those 65 and older [4]. The United States, like many nations, is experiencing a significant demographic shift, with adults aged 65 and older comprising 22 % of the total population by 2040 [5]. As this population grows, many older adults face increasing difficulty maintaining independence while balancing extended work lives, caregiving responsibilities, and personal health needs. These challenges often make accessing the care necessary for healthy aging difficult.

Since 1965, the U.S. has provided Medicare, a federally funded health insurance program to support this population of individuals over 65. Those at greatest risk of economic instability may also qualify for Medicaid, a joint federal and state program that provides additional coverage for low-income individuals [6].

Despite these systems, older adults in New Mexico face persistent barriers to care. These include long travel distances to medical services [7,8], limited public transportation, and seniors increasingly acting as caregivers for loved ones. These structural challenges underscore the urgent need for innovative, community-based models of care that can improve access, coordination, and outcomes for aging populations [9]. In addition, like most states and many countries, we face significant healthcare workforce shortages in the post-pandemic healthcare labor market [10].

In 2023, the New Mexico Medicaid program, in collaboration with the University of New Mexico, the ICOPE team in Toulouse, Occitanie, France, and the World Health Organization (WHO), committed to developing an ICOPE program tailored for New Mexico’s senior population.

1.1. Pre-implementation planning

Through an agreement between the New Mexico Medicaid program and the University of New Mexico (UNM) Hospital and the School of Medicine, an interdisciplinary team was created to undertake program development work. This article describes the steps to create and implement the ICOPE program in our state. A second edition of the ICOPE manual was released earlier this year [11] and used as the template for developing our program. This new manual, to our reading, contained five important major changes:

• 1.Greater emphasis on community integration.
• 2.Including Urinary Incontinence as a key factor for assessment.
• 3.Changing the high-level ICOPE process from five steps to four.
• 4.Inclusion of social support and resources for the participant and their caregiver.
• 5.Adding filter questions for three of the intrinsic capacities (cognition, vision, and audition)

This new ICOPE approach follows a four-step, person-centered assessment and care pathway. Step 1 is a basic assessment to identify potential losses in intrinsic capacity (IC), plus assessments of key factors. Step 2 involves an in-depth, person-centered evaluation to confirm deficits in intrinsic capacities and their causes. Step 3 is the development of a personalized care plan that includes targeted preventive interventions, messages, and resources tailored to the individual's intrinsic capacity status. Step 4 focuses on the implementation and monitoring of the care plan through a coordinated referral pathway, engaging with a multidisciplinary team that spans health, social services, and community-based support. As of 2025, 81.8 % of households with adults aged 65 and older in New Mexico have a broadband internet subscription and a device such as a computer, smartphone, or tablet [12]. This suggests that a significant portion of older adults in New Mexico have access to digital devices, including smartphones. With this in mind, we decided to create a custom-made, senior-friendly mobile health application as the key tool to deliver the New Mexico ICOPE program, allowing seniors to screen and assess their intrinsic capacities and receive results tailored to their priorities for English and Spanish speakers.

To evaluate the program’s impact, the state will initially focus on our approximately 44,000 dual-eligible individuals—those continuously enrolled in both New Mexico’s Medicaid and Medicare programs—as a key population [13]. We hope to expand the program over the next several years to reach the over 400,000 New Mexicans aged 65 and older [14].

We developed an Executive Team composed of representatives from New Mexico Medicaid leadership, local community organizations serving seniors, primary care physicians who actively care for New Mexico Seniors, and a representative from the Toulouse ICOPE team. This group met monthly for a year to develop the overall approach to the design of the New Mexico ICOPE program.

A Core Team was developed and met weekly during 2024 to support the efforts of the Executive Team and to identify additional resources needed to successfully implement the program. Members of the Core Team are all employed by the University of New Mexico School of Medicine and the College of Population Health; two are primary care physicians. The New Mexico ICOPE UNM Core Team is responsible for the day-to-day management, coordination, and operational oversight of the program. This team leads strategic planning, supports clinical and data infrastructure development, liaises with external partners, and ensures alignment with state and national aging priorities. It also facilitates collaboration across stakeholders (Executive Team), supports the implementation of stakeholder recommendations, and drives the program’s continuous quality improvement and evaluation efforts. Appendix Table 1 shows detailed teams roles.

As part of our strategic planning, we created a mission statement and four goals for the New Mexico ICOPE program.

Our Mission: Empowering New Mexico's seniors through prevention and person-centered care, enhancing health, independence, and quality of life by improving services, resources, and community support for healthy aging.

1.2. Goals

• 1.Partner with Existing Resources. Develop mutually beneficial relationships with communities, healthcare, and government organizations to create a sustainable ICOPE program.
• 2.Develop Infrastructure. Build a strong infrastructure for the New Mexico ICOPE program for seamless, effective patient-centered care management.
• 3.Empower Individuals. Ensure a care model that centers on the needs and wishes of seniors across New Mexico and promotes equitable health and quality of life outcomes.
• 4.Evaluate and Advocate. Assess the program's ability to equitably enhance seniors’ care experiences and outcomes, reduce care costs, and to be sustained in New Mexico and disseminated across the United States.

Based on the recommendations of the Executive Team, two additional teams were created within our institution to implement and assess the program, called the Operations Team and the Evaluation Team, respectively. These two teams each meet frequently to further develop the program and its assessment in New Mexico.Through regular Core Team and Executive Team meetings, we defined the scope of our work, our priority population, and key tasks for the development of the New Mexico ICOPE program in our state. Program development priorities were shaped by New Mexico’s largely rural and medically underserved landscape. To effectively reach older adults outside traditional healthcare settings, the approach focused on minimizing clinician touchpoints, leveraging technology, and utilizing community-based resources. This strategy enables ICOPE capacity assessments and the delivery of non-medical support to take place in home or community-centered environments.

1.3. Community partnership development

To support community engagement in the implementation of the New Mexico ICOPE program, a Community Advisory Council was established following outreach to multiple organizations serving older adults. The New Mexico ICOPE Community Advisory Council serves as a guiding body to provide strategic insight, and collaborative support for the implementation and sustainability of the New Mexico ICOPE program in the community. Furthermore, participation in the Community Advisory Council provides a structured avenue for stakeholders to inform partnership strategies. This include reaching out rural areas where literacy and digital access could be a challenge, working in collaboration with a dedicated Community Health Worker who is part of the ICOPE Core Team and offering insights that enhance program implementation to ensure the program remains responsive to the needs and priorities of our state’s senior population.

Council members act as ambassadors, contribute their expertise, and help foster partnerships to promote healthy aging and improve outcomes for older adults in New Mexico.

To ensure the program's sustainability, we leveraged existing resources. We fostered mutually beneficial relationships with a variety of partners, including managed care organizations who provide different health plans such as Medicare and Medicaid programs, and coordinate healthcare services within a network of doctors, primary care clinics and a variety of other providers; government organizations; senior community programs; and non-profit organizations across the state. These partners enable us to utilize existing resources while incorporating the WHO-ICOPE framework to create a sustainable program. Stakeholder collaboration is critical to the New Mexico ICOPE program’s implementation and dissemination strategy. They will promote ICOPE efforts by distributing culturally tailored informational materials (e.g., flyers, posters, newsletters), developing digital content (e.g., websites, blogs, podcasts), and organizing community-based events targeting older adults. Additionally, stakeholders play a vital role in supporting digital health literacy by assisting older adults with smartphone use, navigating app stores, and providing access to the New Mexico ICOPE application (NM ICOPE App) via QR codes. Local organizations are also encouraged to integrate their resources and services to support healthy aging and contribute to the ongoing assessment of ICOPE health domains. Managed care organizations will assist and facilitate resources aligned with ICOPE to reduce time and constraints from our healthcare delivery system.

We developed an implementation Project Plan based on goals and necessary tasks to accomplish project milestones. See Appendix Fig. 1 for Implementtion Timeline.

1.4. Adaptation of WHO clinical algorithms to New Mexico

New Mexico faces a distinct set of health challenges that significantly influence how care must be delivered across the state. Almost 14 % of seniors live at or below the federal poverty level, with about one-third residing in rural areas, often far from healthcare services [15,16]. The state has experienced a persistent shortage of all types of healthcare professionals, limiting access to preventive and intervention care. Language and cultural barriers further complicate access—about 32 % of New Mexicans speak a language other than English at home, and services that are linguistically or culturally aligned are often under-resourced and understaffed [1]. Diseases of despair, including substance use and suicide, are especially prevalent, with New Mexico ranking highest in the nation for alcohol-related deaths [[17], [18], [19]]. Some of these disparities are rooted in the state’s history of colonization and historical trauma, contributing to a distrust of the medical system [19].

To address these challenges, it is essential to design care models that are responsive to the realities of New Mexico’s diverse communities, particularly its elders. Prioritizing care that can be delivered in the physical and psychological safety of home or community settings offers a powerful opportunity to engage those at highest risk of capacity loss due to delayed assessments. The NM ICOPE App aims to demonstrate that healthcare engagement can be participant-driven, allowing individuals to determine when and how to take the next step in their care journey.

The NM ICOPE App’s self-assessment model helps introduce key health needs to those lost to prevention-based healthcare, either due to experiencing healthcare settings as disorienting or being unable to utilize existing healthcare spaces due to work or caregiver responsibilities. While it is common for one spouse to serve as the primary caregiver for the other, the NM ICOPE App’s personalized care plans and prompts will serve as a vital navigation tool for these individuals, helping them stay engaged in their health while balancing the demands of caregiving and other responsibilities.

The NM ICOPE App integrates evidence-based clinical algorithms that guide the identification of common conditions that impact key capacities in older adults. We have tailored these algorithms to address issues specific to New Mexicans, ranging from dry eyes caused by the arid climate to challenges related to substance use. These algorithms will convert participant self-assessment data into personalized care plans, serving as a shared decision-making tool to enhance clinical efficiency and support care aligned with older adults' priorities.

Recognizing that many clinicians may not have specialized training in geriatrics, a web-based platform includes clinician-facing resources to enhance confidence and competence in delivering age-appropriate care. These resources include clinical documents to support primary care physicians in counseling patients on the prevention of declines in each of the ICs, as well as resources which guide the diagnosis, treatment, and supportive care for identified declines in ICs when identified by the ICOPE App. Additionally, the NM ICOPE App’s built-in reassessment tools and behavioral prompts are designed to reinforce sustained health behaviors, addressing a common gap in post-visit follow-through. Expert-informed algorithms also help prioritize referrals to specialist providers, often concentrated in urban centers and operating at capacity, to support appropriate and resource-efficient referrals. This approach supports clinical decision-making and helps mitigate the impact of workforce shortages in these high-need areas.

While the initial implementation includes two language options—English and Spanish—the NM ICOPE App is designed to adapt to other communities. By leveraging the statewide accessibility of app-based assessments, we aim to demonstrate that older adults across New Mexico can benefit from this innovative supplement to usual healthcare delivery, one that emphasizes maintaining and strengthening capacities essential for independent living. Through this approach, we hope to evaluate and measure improvements in health outcomes, directly supporting the objectives outlined in Goal 4.

Given the support provided by New Mexico Medicaid, we are working in collaboration with Medicaid managed care organizations that deliver Medicaid services to residents to identify and engage non-health professionals who can assist with basic assessments. Some managed care organizations already operate mobile health units and home-based care services which can be used to support assessments in rural areas. In addition, many non-profit organizations, some of which are represented on our Community Advisory Council, also provide home-based services. By leveraging the plug-and-play functionality of the NM ICOPE App, this approach aims to address healthcare provider gaps while supporting older adults in improving and maintaining their health across key functional domains.

As part of the development of algorithms for NM ICOPE mobile App, we assessed optimal assessment flow strategies to enhance usability and clinical relevance for older adult users. Two approaches were evaluated: a vertical model, in which users complete all Basic Assessments before proceeding to any In-Depth Assessments, and a horizontal model, where each Basic Assessment is followed immediately by its corresponding In-Depth Assessment if criteria are met. Filter questions were identified as a useful tool to streamline the process, reduce user fatigue, and minimize unnecessary delays in care within the realities of our healthcare system. We also examined the sequencing of intrinsic capacity (IC) domains to align assessments with the functional dependencies and priorities of older adults. To ensure a person-centered experience, app algorithms were designed exclusively for participants, while clinical guidance for healthcare providers will be hosted on a complementary ICOPE New Mexico website, referenced in each personalized individualized care plan. See Appendix Table 2 for detailed model development.

After answering these questions, we developed six IC algorithms and three additional key factor algorithms for Urinary Incontinence, Social Support and Carer Support.

Each of the algorithms was developed in collaboration with both primary care and specialty providers. One of the primary goals of our app development is to shorten the time between the initial identification of an IC deficit and access to needed care. The algorithms are designed to be completed at regular 3-month or 6-month intervals to ensure we are capturing IC declines in a timely manner. Once the IC algorithms were complete, programmers began designing a mobile smartphone App to guide participants through the ICOPE process.

1.5. New Mexico ICOPE mobile application development

The New Mexico ICOPE program is building the infrastructure to support a comprehensive, person-centered approach to healthy aging. Central to this initiative are customized clinical algorithms, a mobile health application, and a dedicated website—all tailored to meet the needs of older adults in New Mexico. The program’s information technology team ensures compliance with U.S. privacy regulations, while legal advisors are developing appropriate user disclosures, intellectual property protections, and disclaimers to safeguard user data and program integrity.

The NM ICOPE App represents a shift from reactive, clinician-initiated care to a proactive model that empowers older adults to engage in their health management. By offering app-based self-assessment of intrinsic capacity domains—including cognition, nutrition, mobility, vision, hearing, mental well-being, urinary incontinence, and social and caregiver support—the platform supports early identification of functional decline and personalized interventions. This digital tool reduces geographic, time, and access barriers, enabling timely preventive care and streamlining the path to healthier aging for seniors across New Mexico.

Considerations in the NM ICOPE App’s initial design were to ensure cross-platform development across standard mobile operating systems, a senior-friendly App user interface with special considerations made to a targeted user experience, including visual formatting/elements and ease of navigation, and an emphasis on participant data privacy and security. Additional functionality within our App to ensure successful adoption includes: 1. notifications to remind participants to complete assessments or provide feedback on achieving their stated goals, 2. personalized care plans based on participants' input to the assessments and recommendations generated from the App’s algorithm, and 3. the ability to complete assessments without a live internet connection. To reduce digital divide and potential challenges of a new mobile App for seniors, we will conduct focus groups and surveys regarding the use of these technologies among seniors in collaboration with our community partners to develop the NM ICOPE App and testing of the platform. Following field deployment, the NM ICOPE App will be redefined through a structured, data-driven process. A built-in user satisfaction survey will collect feedback on usability, clarity, and perceived value, complemented by engagement analytics and clinical relevance assessments. Insights will guide enhancements to the app’s interface, decision-support algorithms, and personalization features. Redesign efforts will improve patient engagement, optimize reminders and reporting, and expand system integration—supporting continuous improvement and sustainable, person-centered care for seniors. See Appendix Fig. 2 for IC structure model.

The New Mexico ICOPE program seeks to identify barriers and facilitators for ICOPE implementation in New Mexico using the mobile application. The team will leverage partner organizations' existing services and community events to integrate resources into the App and support promotional outreach. For instance, the team collaborates with the local organization Meals on Wheels, offering specialized meal plan delivery services in the Albuquerque urban area, such as lower or higher potassium meals for kidney management diets, services that can be integrated into the App as a resource for the intrinsic capacity for malnutrition as a local adaptation for those seniors with specific risk factors. To further complement resources for nutrition, the NM ICOPE App will include references for appropriate dietary guidelines to align with individual support needs. In addition, the program aims to assess the social care support available to seniors and provide resources, including the One Albuquerque Department of Senior Affairs, the New Mexico American Association of Retired Persons, and the New Mexico Caregiver Support Services, all of which can be embedded into the App. This approach is applied to identified areas of concern for each intrinsic capacity based on the existing partnerships and local services available. Simultaneously, the program invests in a sustainable data infrastructure for long-term evaluation and continuous quality improvement. This includes establishing the technical capacity to integrate the New Mexico ICOPE program data with the Medicaid/Health Care Authority data lake containing state Medicaid claims data, which will support robust analytics for evaluating outcomes and refining program implementation.

1.6. Information systems

As patients use the NM ICOPE App by downloading and registering themselves and then working through the ICOPE assessment processes, the data generated from the App from each participant will be securely sent to a cloud storage service. The NM ICOPE App employs cloud-native technologies to enable flexible and interoperable data sharing across care settings. Health data collected within the App is stored in JavaScript Object Notation (JSON), a structured, text-based format that supports standardization. This allows for efficient mapping to FHIR (Fast Healthcare Interoperability Resources) standards, facilitating integration with external repositories [20]. Partnering with the New Mexico Health Care Authority (NM HCA) and Medicaid, we plan to securely send de-identified and aggregated data from the app to a large electronic database at the NM HCA for analysis by the ICOPE evaluation team.

Fig. 1 shows how generated data would flow from the user to the NM ICOPE App, to secure cloud storage, to the NM HCA repository. From the NM ICOPE App’s internal aggregate data, we hope to understand the App’s collective usage by participants, including ICOPE process completion, re-evaluation rates, and anonymous feedback from users to improve the App’s design, functionality, and usefulness.

Fig. 1.

ICOPE New Mexico application data flow.

New Mexico seniors will interact with the NM ICOPE App with data from the App sent to a secure and HIPAA-compliant cloud storage service. Only aggregate and de-identified data will be accessible by New Mexico ICOPE program for evaluation and reporting purposes. Aggregated data will be securely sent to the NM Health Care Authority state database for further analysis related to the use of healthcare resources and health outcomes.

1.7. Evaluation of the New Mexico ICOPE program

The New Mexico ICOPE evaluation team will assess the program’s ability to improve senior care outcomes, reduce costs, ensure sustainability, and support future expansion across the U.S. The team includes experts in epidemiology, biostatistics, health economics, data science, implementation science, and geriatric care, ensuring a comprehensive and equity-focused evaluation.

A mixed-methods, hybrid type 2 implementation-effectiveness evaluation [21] design guided by the Practical, Robust Implementation and Sustainability Model PRISM framework will evaluate the program [22]. This model examines reach, effectiveness, adoption, implementation, and maintenance, all shaped by contextual factors such as leadership support, usability, infrastructure, participant characteristics, and external influences like reimbursement. The NM ICOPE evaluation will have two aims (Fig. 2):

• 1.to identify contextual factors influencing New Mexico’s ICOPE adoption, implementation, and maintenance from multiple stakeholder perspectives.
• 2.to evaluate ICOPE reach and impact on older persons and health care system outcomes in New Mexico.

Fig. 2.

ICOPE New Mexico program evaluation aims and methodology based on PRISM framework.

For Aim 1, we will gather data about contextual factors and organizational adoption, implementation, and maintenance of New Mexico ICOPE program by iteratively conducting interviews or focus groups with older adults and their caregivers, leadership, management, and staff representatives from NM health care and community organizations involved in New Mexico ICOPE program implementation. An iterative, inclusive approach will ensure that experiences and perspectives from New Mexicans directly shape the evolution of the program. We will also gather information for Aim 1 from the New Mexico ICOPE Core Team, Executive Team, and Community Advisory Council meeting notes. The qualitative data gathered for Aim 1 will be thematically analyzed using the process outlined by Braun and Clarke [23]. Themes will be synthesized and reported based on PRISM. The analysis for Aim 1 will identify barriers, facilitators, and solutions to New Mexico ICOPE program adoption, implementation, sustainability, and reach in our state. Expected outcomes include institutional and individual support recommendations to strengthen New Mexico ICOPE program implementation and reach among seniors.

For Aim 2, the New Mexico Health Care Authority will provide access to a de-identified dataset including information about ICOPE engagement, patient characteristics, and New Mexico’s Medicaid claims data. This data analysis will be initiated around 12 months after the New Mexico ICOPE program is launched, and analysis will continue yearly through the end of the evaluation. We will summarize our monthly reach over time. To estimate impact, we will focus on the Institute for Health Care Improvement’s Triple Aim framework: seniors’ experience of care, population health, and the cost of care [24]. We will evaluate experience of care based on satisfaction with ICOPE and identification of and preventive messaging for intrinsic needs; population health based on health-related quality of life, morbidity, mortality, preventable hospitalizations, emergency department visits, hospital readmissions, and risk of high pharmacy use; and cost of care based on cost to the NM Medicaid program. We will use mixed-effects generalized linear, logistic, Poisson, or negative binomial regression models, as appropriate to the outcome of interest. All models will include a variable specifying engagement with the ICOPE clinical intervention (the primary exposure of interest) and will account for the hierarchical structure of the data. To improve causal inference in this observational cohort, we will use propensity score matching or adjustment [25,26]. We will conduct planned subgroup analyses and examine effect modification by race, ethnicity, sex, socioeconomic status, and rurality, to assess whether the ICOPE approach promotes equity in health outcomes and to identify unintended negative consequences (e.g., if the approach widens existing racial and ethnic disparities in health outcomes). The quantitative analyses for Aim 2 will produce estimates of NM ICOPE’s effect on key outcomes for seniors and the health care system in a real world, New Mexico context.

2. Conclusion

A multidisciplinary and multi-stakeholder group has established the ICOPE implementation plan for New Mexico. This is a unique collaboration between the New Mexico Medicaid program, the University of New Mexico Hospital, and the University of New Mexico School of Medicine, working alongside an Executive Team, Evaluation Team, Operations Team, and Community Advisory Council. This collaborative approach ensures that the NM ICOPE App and its subsequent implementation and evaluation, align with ICOPE principles that prioritize person-centered, coordinated care to optimize intrinsic capacity and functional ability in older adults in New Mexico, and in the future, other states across the United States of America.

CRediT authorship contribution statement

Rodriguez de Sosa GM: Writing – review & editing, Writing – original draft, Visualization, Validation, Supervision, Software, Resources, Project administration, Methodology, Investigation, Conceptualization. Shera AL: Writing – review & editing, Writing – original draft, Supervision, Resources, Methodology, Investigation, Conceptualization. Jimenez EY: Writing – review & editing, Writing – original draft, Validation, Resources, Methodology, Investigation, Conceptualization. Patel IA: Writing – review & editing, Writing – original draft, Software. Greenwood-Erickson MB: Writing – review & editing, Writing – original draft, Validation, Methodology, Investigation. Wilkins KD: Writing – review & editing, Writing – original draft, Validation, Investigation. Vlietstra L: Writing – review & editing, Methodology, Investigation. Dancis AK: Writing – review & editing, Supervision, Methodology, Funding acquisition. Bartsch CK: Writing – review & editing, Supervision, Methodology, Funding acquisition, Conceptualization. Andrieu S: Writing – review & editing, Resources, Investigation, Conceptualization. Hwang JW: Writing – review & editing, Validation, Methodology, Investigation. Scrase DS: Writing – review & editing, Writing – original draft, Supervision, Resources, Project administration, Methodology, Investigation, Funding acquisition, Conceptualization. Waters DL: Writing – review & editing, Writing – original draft, Validation, Methodology, Investigation, Funding acquisition.

Declaration of competing interest

The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: Giselle Rodriguez de Sosa, Annashia Shera and David Scrase report financial support was provided by The University of New Mexico. Giselle Rodriguez de Sosa, Annashia Shera and David Scrase have patent ICOPE New Mexico Program issued to D2025–0068. If there are other authors, they declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

Appendix

Appendix Table 1.

New Mexico ICOPE program team structure and roles.

Operations Team

Evaluation Team

•Coordinates New Mexico ICOPE Program implementation. •Ensure compliance with university, state, and federal policies and regulations. •Designs, develops or assists with clinical algorithms/ program steps, to design the ICOPE New Mexico App. •Co-design data systems with Health Care Authority for the ICOPE New Mexico App and Medicare/Medicaid data systems. •Works with program leadership to manage contracts, grants, state funding, and program reports. •Develop policies and operating procedures. •Collaborates with university departments, State and local governments, local and state health systems, and community and social service organizations to consolidate resources and enhance programs.

•Design and conduct evaluation of ICOPE Program in New Mexico •Review and summarize peer-reviewed literature on ICOPE implementation to inform team efforts. •Co-design data systems for New Mexico ICOPE Program Evaluation. •Secure funding for research and evaluation of the ICOPE Program in New Mexico.

Appendix Table 2.

New Mexico ICOPE program steps for intrinsic capacity algorithm model development.

Step	Description	Comment/Example
1	Begin with the basic structure of the Intrinsic Capacity algorithm provided by the WHO in ICOPE second edition as the skeleton for the App.	We adapted the basic participant-facing sections of the ICOPE roadmaps in flowchart software.
2	Modify the algorithm to best fit the existing resources and capabilities of the healthcare system in New Mexico.	We identified specific potential community resources relevant to each IC, e.g., home delivered meals for the Nutrition IC.
3	Use community input from older people to rename the ICs*	Memory and Thinking Moving Around Healthy Eating Seeing Clearly Hearing Well Emotional Health Bladder Control Help from Others Assistance for People who take Care of Others
4	Carefully consider each potential referral into the existing healthcare system to determine whether a community-based resource could provide needed gathering of additional data or provision of services.	We explored multiple avenues to determine whether any of the available cognition assessment tools could be administered by Community Healthcare Workers.
5	Review the algorithm with key stakeholders including community members, primary care providers, and specialists.	We reviewed the Depression IC algorithm with experienced behavioral health providers to ensure a good fit with existing provider and community resources.

Appendix Fig. 1.

New Mexico ICOPE Program Implementation Timeline.

Appendix Fig. 2.

New Mexico ICOPE program intrinsic capacity algorithm structure model.