Developing an integrated dementia care model using service blueprinting: process visualization and failure point analysis

Abstract

Background and objectives

With the increasing burden of dementia, existing health service systems still face challenges such as fragmentation and lack of continuity, making the establishment of an integrated service model imperative. This study aimed to use the service blueprint method to systematically visualize the entire service process, identify key failure points, and provide a basis for constructing a person-centered integrated dementia care model.

Research methods

This descriptive qualitative research was conducted in Wuhan, Hubei Province, China, from July 2023 to November 2025. Data were collected using semi-structured interviews with both service user and provider groups to explore the content and challenges of the entire service process from multiple perspectives. The data were then organized and analyzed using service blueprints.

Results

Based on the findings, a blueprint for dementia care was constructed, following a timeline from prevention and screening through diagnosis and intervention to the chronic management period. Patient-side exhibited 12 types of behaviors, including “information seeking and learning” and “undergoing cognitive function screening”. Healthcare institutions carried out 11 types of onstage (visible) employee actions, such as “active promotion” and " risk factors intervention”, as well as five types of backstage (invisible) employee actions, including " cross-institutional collaborative " and “information sharing and interoperability”. Support systems comprised four categories, including “information technology and data platforms” and “organizational management and operational support”, which underpinned the entire process. Furthermore, 19 service failure points were identified across all stages.

Discussion

This study systematically visualized the entire dementia care process via a service blueprint, revealing critical failure points. The most prominent system issues included resource shortages and a disconnect between policy systems and actual service needs. Backstage employee actions reflected insufficient proactive collaboration among institutions, while onstage employee actions showed inadequate interaction between service users and providers. Corresponding countermeasures were proposed, providing empirical evidence and directions for advancing an integrated service model.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-026-14782-x.

Introduction

Dementia in older adults is a neurodegenerative disorder characterized by cognitive decline, memory impairment, and abnormal behavior. It has an insidious onset, a long course, and progressive aggravation, and currently has no effective cure [1]. In recent years, the global number of older adults with dementia has continued to rise. It is estimated that by 2050, this number will reach 152 million, imposing an increasingly severe caregiving and economic burden on families and society [2].

In response to this challenge, global evidence indicates that strengthening prevention efforts can help maintain cognitive function or slow its decline [3, 4], while early diagnosis facilitates timely intervention [5]. Furthermore, early and comprehensive intervention can effectively delay cognitive deterioration [6], and continuous professional support services can significantly reduce the burden on caregivers while improving the quality of life for patients and their families [7]. Therefore, to systematically address the multiple burdens brought by dementia, it is necessary to adopt a comprehensive, continuous, and integrated health service model. Such a model should promote the seamless integration of medical resources across the entire continuum from prevention, screening, and diagnosis to intervention and chronic management, and rely on multi-sector collaboration and strong system support to achieve service integration [8, 9].

For decades, policies worldwide have championed people-centered integrated care and the development of cohesive health service delivery systems [10–13]. However, dementia care for older adults continues to confront critical challenges: inefficient medical resource allocation and insufficient implementation of tiered healthcare arrangements [14, 15]; fragmented coordination across hospitals, communities, and families, which undermines the continuity and integrity of care [16]; and insufficient provision of essential services spanning early prevention, screening, and long-term support of elderly dementia is insufficient [17–19]. Collectively, these deficiencies highlight a substantial gap between the current service performance and policy aspirations for dementia care. Consequently, a well-defined and operationally feasible integrated health service model for elderly dementia remains to be established [16–19].

A service blueprint is defined as “a diagram that visualizes the relationships between service components directly related to a specific customer journey, illustrating how a company delivers user experience.” Although this method originated in enterprise service management, it is particularly suitable for handling service experiences that involve complete processes, multiple touchpoints, and require cross-departmental collaboration ——this is the core characteristic of integrated healthcare services [20]. In healthcare services, the service blueprint typically segments services into four levels: patient-side behavior, onstage/visible contact employee actions, backstage/invisible contact employee actions, and support systems. These are structured through three dividing lines: the line of interaction (separating customer actions from service provider actions), the line of visibility (distinguishing visible and invisible activities), and the line of internal interaction (separating support activities from other internal operations [21]. Therefore, the service blueprint can visually depict who receives the services, what each service entails, and how it is delivered. It also reveals optimization opportunities through visualization, thereby enhancing service efficiency [22]. Furthermore, it helps service providers examine both their own and their partners’ work from a systemic perspective, understand their impact on patient experience, and identify multi-faceted areas for improvement [23]. Compared to traditional process descriptions or single-dimensional qualitative analysis, the unique advantage of service blueprints is that they can clearly distinguish between ‘visible’ and ‘invisible’ service activities for patients, accurately identify current challenges in the health service chain, and present results in visual charts to facilitate cross-institutional collaboration and decision-making. Currently, service blueprint has been applied and proven effective in multiple healthcare scenarios, such as optimizing elderly health examination services [21], establishing a communication and support platform for head and neck cancer patients [24], and visually presenting the triage process for high-volume emergency patients [25]. These healthcare applications have demonstrated the applicability and effectiveness of the service blueprint method, thereby establishing a methodological basis for its use in this study to explore integrated health services for older adults with dementia.

In summary, to explore and address the problems of “unclear reasons for fragmentation and lack of integrated models” in current dementia health services, this study constructs an integrated health service blueprint model for older adults with dementia based on the service blueprint method. This model aims to integrate dispersed medical, nursing, social, and family resources into a clear, coherent, and person-centered service pathway. Through visualization, this study presents the complete process of service process, inter-institutional collaboration mechanisms, and backstage support systems, thereby enhancing service transparency and management efficiency. Unlike previous studies that merely described service processes, this study further applies the service blueprint method to systematically identify critical bottlenecks throughout the entire service process, pinpoint specific areas for improvement, and propose targeted optimization strategies. The findings provided empirical evidence for addressing challenges such as suboptimal resource allocation, fragmented service delivery, and insufficient collaboration, but also laid a theoretical foundation and provided practical tools for constructing a scalable integrated health service model for older adults with dementia.

Methods

Study design

This study employed a qualitative descriptive research methodology. Data were collected through semi-structured interviews, with two groups of participants: informal caregivers of older adults with dementia and health service providers, to explore the content and needs of health services throughout the entire disease course from multiple perspectives. Data were analyzed using the patient service blueprint as the organizational framework.

Participants and data source

This study was conducted in Wuhan from July 2023 to November 2025. To ensure comprehensive and detailed data collection from various stakeholders involved in dementia care for older adults, the study included the following groups: informal caregivers (patient-side) of older adults with dementia, medical staff in hospitals, general practitioners in primary healthcare institutions, and nursing staff in long-term care institutions, aiming to understand the implementation of full-course health services for this population. The inclusion and exclusion criteria for participants are as follows.

Informal caregiver of patients with dementia (Patient-side)

All interview data were derived from informal caregivers as patients themselves were not directly interviewed. Informal caregivers were recruited through purposive sampling.

Inclusion criteria include:

1. Care for an older adult with dementia diagnosed according to the third edition of the Chinese Classification and Diagnostic Criteria of Mental Disorders (CCMD-3);

2. Providing long-term care and residing with the patient;

3. Providing a signed informed consent form and voluntarily agreeing to participate in the interview.

Exclusion criteria:

1. Caregivers with mental illness or serious physical illness.

Hospital medical staff

Medical staff were recruited through purposive sampling, and included if they met the following criteria:

1. Had experience in treating patients with dementia;

2. Provided informed consent;

3. Voluntarily agreed to participate in the interview.

General practitioners in primary healthcare institutions

General practitioners employed by primary healthcare institutions were recruited through purposive sampling and included if they met the following criteria:

1. Had experience in managing patients with dementia;

2. Provided informed consent;

3. Voluntarily agreed to participate in the interview.

Nursing staff in pension institutions

Nursing staff employed by long-term care institutions were recruited through purposive sampling and included if they met the following criteria:

1. Had experience in caring for patients with dementia;

2. Provided informed consent;

3. Voluntarily agreed to participate in the interviews.

Data collection

Interview outline development

This study aimed to systematically present patients’ experiences and perceptions throughout the entire disease process and to establish an analytical foundation based on the service blueprint framework. To achieve this, a semi-structured interview outline was initially drafted through literature review and internal team discussions. Subsequently, two participants from each target group were recruited for pre-interviews. Based on feedback from these pre-interviews and suggestions from relevant experts, the outline was revised and refined, ultimately forming a formal interview outline (see Additional file 1 for details).

Sampling strategy

This study adopted a maximum variation sampling strategy within purposive sampling [26], aiming to capture diverse perspectives across different stakeholders and contexts in dementia care for older adults and obtain rich and heterogeneous qualitative data. Specifically, given the involvement of multiple groups and institutions, interviewees were selected to represent variation ages, genders, educational backgrounds, professional titles, work experiences, and caregiving durations, thereby capturing a broad range of experiences and perspectives. Within the informal caregiver sample, caregivers of patients with varying disease stages and severity levels were included to cover the caregiving trajectory from early to late disease.

Data collection and quality control

The interviewer arranged a quiet and private space for each interview to ensure that participants could express their personal experiences and feelings without disturbance. The interviews are conducted in Chinese, and all participants are asked the same core questions; however, researchers could adjust the question order as appropriate to maintain the naturalness and coherence. Interviews in which participants could not actively cooperate or whose content significantly deviates from the research objectives were excluded from the final analysis. There was no predetermined time limit for the interviews. This study used the principle of data saturation to determine the final sample size. Data collection and analysis proceeded simultaneously: after each interview, the recording was immediately transcribed, and two researchers independently performed initial coding and identified preliminary themes. For the four respondent categories (informal caregivers, hospital medical staff, general practitioners, and nursing staffs in pension institutions), saturation was deemed achieved for a given category when no new codes or themes emerged from three consecutive interviews within that category. In addition, member checking was used in the interviews. After preliminary analysis, the findings were returned to participants, who were asked to verify whether these contents accurately reflected their experiences, perspectives, and intentions, thereby ensuring the validity, credibility, and ethical rigor of the research.

Data analysis

Within 24 h after each interview, recordings were transcribed verbatim and reviewed for accuracy. Researchers identified and selected words and phrases relevant to research objectives, condensed it while retaining the core content, and provided a comprehensive and direct description of the medical service content and needs throughout the entire course of dementia. The specific analysis processing the service blueprint method was as follows: First, all interview transcripts were imported into NVivo 14 and coded using thematic analysis [27] to extract initial codes related to “patient-side behavior”, “front-end behavior”, “back-end behavior”, and “support system”. Based on the service blueprint framework, these codes were classified into the four levels mentioned above. Second, various obstacles in the service delivery process was identified and mapped to corresponding stages, levels, and boundaries of the service blueprint.

Results and analysis

Research participants: sociodemographic characteristics

Data saturation guided sample size determination. For example, regarding the prevention phase, caregivers reported that their knowledge of the patient’s condition was acquired through family history of dementia” (once), " health lectures at medical institutions” (three times), " media channels” (five times), and “consultation with family and friends” (three times), no additional sources emerging thereafter. In addition, six caregivers reported that they had been unaware of dementia prior to the patient’s illness. Following this saturation principle, a total of 16 informal caregiversof older adults with dementia, 14 medical staff from five hospitals, 13 general practitioners from seven primary healthcare institutions, and 16 nursing staffs from seven long-term care institutions were ultimately included. Descriptive statistical methods were used to summarize respondent demographics. The main characteristics of each group were as follows: 1) Patients and primary caregivers: 11 female and five male primary caregivers, aged 46–84 years, the patients they cared for included ten female and six male dementia patients, aged 71–91 years. Disease duration ranged from 3 months to 17 years; 2) Hospital medical staff: 10 females and four males, including three with senior titles, six with deputy senior titles, four with intermediate titles, and 1 with junior titles. The majority had a master’s degree (71.4%); 3) Primary care general practitioners: five were female, and nine were male. The majority (76.9%) held intermediate professional titles, and the majority (69.2%) held bachelor’s degrees; 4) Long-term care institution nursing staff: the sample includes 15 females and one male, with the majority being middle-aged (68.8%). The education level was generally low, with 62.5% having a junior high school education or below. Detailed demographic characteristics can be found in Additional file 2–5. All interviews were conducted face-to-face, with an average interview time of 30 minutes, and all recordings were transcribed.

Blueprint for dementia health services in older adults

Figure 1 depicts the entire process of health services for dementia in older adults, encompassing prevention, screening, diagnosis, intervention/treatment, and chronic management. The blueprint is read from left to right: the horizontal axis represents the chronological sequence of patient-side behavior and health services, forming a coherent narrative; the vertical axis represents the organizational hierarchy and visibility of health services, revealing how the backstage/invisible contact employee actions and support systems operate at each stage of the patient journey.

Fig. 1.

Blueprint for elderlsy dementia health services. Note: “Fn” stands for Service Failure Point Number. Please refer to Supplementary Table 6 for details

Patient-side behavior

This layer details the behaviors and services experienced by patients and their families throughout the disease continuum, from prevention to chronic management (see Additional file 6). Presenting the process from the user’s perspective is the core of the service blueprint. According to caregiver’s description, in the prevention stage, older adults actively search for and learn about cognitive disorders. During routine physical examinations or medical visits for other illnesses, they may unexpectedly become aware of cognitive decline, which may prompt them to complete cognitive function screening and seek further diagnosis. Subsequently, those with abnormal screening results are typically referred to higher-level medical institutions for systematic evaluation to confirm the diagnosis and obtain detailed explanations about the disease. Upon entering the intervention stage, patients begin standardized treatment, actively report their condition to doctors, and jointly explore better treatment plans. In the chronic management period, service demands increase, and their behavior mainly focuses on basic care and safety guarantee, access and utilization of medical resources, emergency response and crisis management in case of emergencies, and long-term placement and care planning.

Onstage/visible contact employee actions

Onstage/visible contact employee actions refer to the staff and their service behavior who directly contact patients in health service institutions. As these directly target service recipients, their performance crucially impacts the quality of patient management and is a key focus of health services (Additional file 7). In the prevention stage, hospitals and primary healthcare institutions provide dementia prevention services for older adults through proactive promotion and risk factor intervention, and conduct opportunistic and planned cognitive function screening. For older adults with cognitive impairment who seek medical treatment, hospitals provide a clear diagnosis and relevant support services. After entering the treatment stage, hospitals and primary medical institutions play different roles based on their functional positioning, providing professional treatment and coordinating support systems to provide services to patients. When patients enter the chronic management period, hospitals, primary healthcare institutions, and long-term care institutions collaborate to meet the patient’s needs through home-based support services, professional medical services, and the establishment of a continuous care network.

Backstage/invisible contact employee actions

This layer encompasses tasks that support onstage/visible contact employee actions without direct contact with patients. Although not directly aimed at patients, these tasks have a crucial impact on the final quality and effectiveness of services. Onstage and backstage behaviors are interdependent and together form a complete service loop (Additional file 8). In the prevention and screening stage, primary healthcare institutions and hospitals work together to provide prevention information and cognitive function screening for the target population through horizontal collaborative actions, information exchange, and resource allocation. If abnormalities are found, the patient will be referred to a higher-level hospital through a referral mechanism. During the diagnostic phase, hospital doctors can access mutually recognized past examination information, thereby reducing duplicate examinations, alleviating patient burden, and improving efficiency. After entering the intervention phase, long-term treatment for patients may involve primary healthcare institutions. Hospitals and primary healthcare institutions ensure that patients receive sustained and stable treatment through resource allocation and information sharing. When patients enter the chronic management period, hospitals, primary healthcare institutions, and long-term care institutions provide comprehensive health services to patients through various forms such as referral cooperation, resource allocation, vertical collaborative action, and information exchange.

Support system

The support system is the foundational architecture, providing essential infrastructure for all onstage and backstage actions. It does not interact directly with patients but is crucial for systemic functionality (Additional file 9). In the prevention and screening stage, support mainly relies on information technology and data platforms, as well as integrated human resources and training systems, to facilitate inter-institutional interaction behavior. In the diagnostic stage, supporting elements are concentrated in information technology and data platforms to ensure smooth access to patient information and mutual recognition of examination results. During the intervention and chronic management period, the support system is the most complex and comprehensive, including information technology and data platforms, integrated human resources and training systems, and additional support for organizational management and operations, as well as multidisciplinary professional collaboration mechanisms, to meet the patients’ complex long-term needs.

Service failure points

Service failure points were defined as “weak links or interruptions in the service process that are most prone to errors, delays, quality degradation, or customer dissatisfaction, ultimately leading to the unfulfilled service commitments–essentially a “risk point” or “breakdown point” in the service chain (See Fig. 2 and Additional file 10 for details). This study found that the failure points at different stages did not exist in isolation, but rather accumulated through interconnections across the service chain, ultimately leading to single-point failures and system fragility. The specific situation is as follows:

Fig. 2.

Elderly dementia health service blueprint service failure point matrix diagram

In the prevention stage, the primary bottleneck is the fundamental “resource shortage”, which directly leads to the “supply deficit” of prevention services; In addition, the “poor dissemination effect” of disease health education was also a key dilemma. The accumulation of these two failure points caused many potential beneficiaries to miss the opportunity for timely health services, thereby shifting the service pressure to the screening stage.

In the screening stage, the following points of failure exist: the fundamental “resource shortage” directly led to the “supply deficit” of screening services, and the target population exhibited “low awareness and active participation rate” in screening services. These failure points seriously affected the coverage and effectiveness of screening. This caused patients to miss opportunities for early disease identification; by the time they enter the diagnostic stage, their conditions had further developed, thereby increasing the difficulty of subsequent diagnosis and treatment.

During the diagnostic phase, service failure mainly stemmed from three core barriers: First, information barriers (manifested as insufficient cross-institutional information flow) that affected diagnosis and treatment efficiency; Second, economic barriers that limit patient access to diagnostic services; and third, the communication and trust barriers at the doctor-patient interaction level. The cumulative effect of these three berries not only reduced the efficiency of diagnosis and treatment but also may have affected the accuracy and timeliness of diagnosis. This prevented the conversion of initial health service investments into sustained health outcomes, while also increasing the difficulty of subsequent treatment.

In the disease intervention stage, failures were mainly manifested in support system: hospitals exhibited “poor dependence on patient treatment”; Primary healthcare institutions are plagued by fundamental ‘resource shortages’, ultimately affecting the coherence and effectiveness of intervention outcomes. This led to partial loss of initial investment from prevention through diagnosis due to weak support systems, making it difficult for patients to receive sustained intervention after discharge.

During the chronic management period, the main problem in hospitals was the inefficiency of patient management tools and models, which made it difficult to ensure regular follow-up visits. Primary healthcare institutions faced more serious challenges, including lack of a service payment mechanism, unclear definition of responsibilities, lack of sustainable payment mechanisms, and broken disease management chains, which prevent their core role from being fully realized. Meanwhile, long-term care institutions were limited by the dual scarcity of human resources and environmental hardware, weak external support networks, and difficulty in integrating into patients’ long-term networks due to low willingness to accept patients and payment difficulties These failure points accumulated layer by layer, ultimately leading to the overall fragility of the entire health service system.

Discussion

This study adopted the service blueprint method to systematically visualize the entire process of health services for dementia in older adults, covering the complete service cycle from prevention, screening, diagnosis, intervention, to chronic management, and comprehensively mapped its specific content. Through this visualization, the research aimed to clarify the entire disease course, the mechanisms linking each stage, the collaborative relationships among multiple departments, and key support systems, thereby integrating originally fragmented services, resources, and processes into a coherent service chain.

The findings revealed that the existing service system had established several strengths: it had formed a full cycle structure spanning from prevention to chronic management; At the policy level, there was already a clear integrated health service orientation (such as family doctors contracting, etc.); and some institutions have attempted to promote collaboration through information platforms. Therefore, based on this service blueprint, stakeholders could systematically understand resource distribution and service pathways from prevention to chronic management, and efficiently obtain support when needed; service providers could clarify their roles and responsibilities within the overall service network, and better conduct inter-institutional referrals and collaborative cooperation; At the policy and planning level, this blueprint helped visually identify gaps in the existing service system, providing a reference for optimizing resource allocation, designing processes scientifically, and building an integrated health service model for dementia in older adults, ultimately improving patients’ quality of life and reducing the social burden caused by the disease.

Furthermore, this study identified the key bottlenecks in the current service system. There is a dual shortage of human resources and funding at the resource layer, particularly in prevention, screening, and long-term care institutions; The lack of information sharing and referral mechanisms hindered inter-institutional collaboration, manifested as incomplete patient information transfer and fragmented disease management chains; Delays in payment and incentive mechanisms made it difficult to sustain primary care services during chronic management stage; Mismatches between service supply and demand, such as low participation rate in screening, insufficient utilization rate of elderly care institutions, etc.; and support system vulnerabilities, such as incomplete information technology platforms, inadequate professional training systems.

Notably, this study found that service barriers were concentrated at the line of interaction (i.e., the interface between patient-side behavior and front-end behavior), and less so at the line of visibility or the line of internal interaction. This distribution indicated that the core bottleneck of the current dementia service system lay not only in the design of technology platforms or systems, but also in patient–provider interaction. This provided a foundation and actionable recommendations for targeted quality improvement and the future construction of an efficient, comprehensive health service model for dementia in older adults.

Prevention and screening stage: disconnection between supply and demand at the line of interaction amid resource scarcity

In the prevention phase, this study found that the core failure point was the “resource shortage” that directly led to “insufficient supply” of prevention services, alongside the “poor dissemination effect” of health education at the line of interaction. In the screening phase, beyond the “resource shortage”, there was also a problem of “low awareness and low participation rate” among the target population, which is an obstacle at the line of interaction rather at the technical or internal management level. The shortage of resources (both human resources and funding) prevented public health services from covering the entire population. At the same time, medical personnel generally prioritized treatment over prevention, resulting in insufficient supply of prevention and screening services [28, 29]. The poor dissemination effect essentially reflected a mismatch between the health literacy of older adult patients and the information transmission methods of front-line staff, rather than a problem with the information content itself. Education level, mass media exposure, and living conditions were also key influencing factors [30]. The low participation rate in screening was closely related to the long-term stigmatization of dementia in society [31], representing a direct friction between the cognitive bias of the service users and the educational approaches of providers. Personal factors such as age, education level, and social participation also significantly affected residents’ willingness to participate in screening [32].

Based on the evidence, to address resource shortages, it is necessary to strengthen multidisciplinary workforce development [28] and optimize organizational-level incentive mechanisms to encourage medical personnel to engage in disease prevention and screening [29]; Ensure and optimize financial investments to meet the target population’s preference for free services and expand coverage [33]; and explore innovative service delivery models such as outsourcing to alleviate resource shortages [34]. Research supports involving family and community workers to address failures in the line of interaction. Visual and oral materials should be used to disseminate knowledge about dementia risk factors, intervenability, and the importance of early screening, in order to raise awareness and effectively reduce barriers caused by stigma-related disorders [35, 36].

Diagnosis stage: overlapping barriers impeding initial investment and subsequent treatment

The findings revealed that three core barriers existed in the diagnostic stage—information barriers, economic barriers, and communication and trust barriers. Information barriers prevented patient medical records from circulating across institutions, resulting in repeated checks and delays; Economic barriers led some screen-positive individuals to forgo diagnosis [37]; Communication and information barriers were located at the line of interaction, stemming from patients’ uncertainty about diagnostic results, coupled with limited consultation time and insufficient empathetic communication by medical staff. These barriers arose primarily from support system deficiencies rather than individual provider errors, and further reduced patient’s acceptance of subsequent treatment.

Therefore, based on these findings, we recommend building a medical information integration platform to address information barriers and enable seamless sharing of electronic medical records [38–40]. To address economic barriers, first, develop and promote low-cost and high-efficiency diagnostic technologies to lower the diagnostic threshold; second, expand medical insurance coverage and fiscal incentives for dementia care within the support system, thereby alleviating patients’ economic pressure [41, 42]. To address communication barriers, healthcare providers should proactively optimize communication strategies, such as employing empathic skills, establishing and maintaining long-term trust relationships, adopting a family-centered communication model, and using accessible language to convey information about dementia diagnosis and subsequent treatment [43].

Intervention stage: poor treatment adherence and inadequate primary care capacity

The findings revealed that the main failure point in the intervention stage was poor patient treatment adherence, reflecting an indirect impact at the line of interaction: primary healthcare providers were unable to effectively meet patient needs due to weak support systems, yet patients still perceive insufficient onstage services. Meanwhile, primary healthcare institutions lacked medication and professional support. Given limited existing treatment options, patients’ expectations of “cure” are difficult to achieve, leading to a decrease in adherence. Treatment discontinuation due to economic burden further underscored the necessity of strengthening health insurance coverage and financial assistance within the support system. Medication shortages and workforce deficits in primary healthcare institutions essentially represented a continuation of resource shortages during the intervention phase.

Based on these findings, service providers should provide patients with detailed explanations of the natural disease progression and realistic treatment goals (such as maintaining function and improving quality of life), rather than pursuing a cure, to enhance their willingness and motivation for long-term treatment [44]. Meanwhile, personalized intervention strategies could be adopted to adjust treatment goals according to patient priorities. For primary care support, it is necessary to establish a collaborative mechanism covering drug catalogs, prescription circulation, distribution guarantees, and payment incentives, rather than simply increasing stock. In addition, Furthermore, workforce shortages again underscored the importance of workforce development and improving the support system strengthening.

Chronic management stage: concentrated support system vulnerabilities support system vulnerabilities

The findings revealed that failure points in the chronic management stage were most concentrated and clearly manifested as support system issues. These included: a lack of payment mechanisms and unclear responsibility definitions in primary healthcare institutions, a fragmented disease management chain, difficulties in family doctor contracting, inefficient follow-up tools in hospitals, and human resources and environmental hardware shortages and a weak external support network in long-term care institutions. For primary healthcare institutions, the lack of payment mechanisms was not a matter of implementation willingness, but rather a lag in institutional rule design - relevant policies, regulations, and payment systems had failed to keep up with the shift towards person-centered service models. Hospital follow-up relied solely on telephone calls, and patients lacked proactive management awareness, reflecting inefficiency in management tools and models. The dilemma of long-term care institutions was reflected in a dual contradiction between demand (lack of trust, filial piety culture, heavy economic burden) and supply (shortage of human resources, insufficient hardware, high operating costs).

Based on these findings, the following suggestions are proposed: first, incorporate eligible home-based services into basic public health services and establish a sustainable payment mechanism. Meanwhile, clear and feasible referral norms and mandatory interinstitutional information exchange standards should be established within the support system to promote the smooth return of patients to primary care management [45]. Second, to improve hospital follow-up effectiveness, flexible digital tools should be combined with clear standardized processes and embedded into the service support system, such as integrating the Rapid Dementia Rating System (QDRS) into the follow-up process [46]. Third, for long-term care institutions, to alleviate the current supply-demand imbalance, it is recommended that these institutions rebuild their support system, establish more robust support and supervision system, and consider introducing family participation models in care [47–49]; To address the dilemma of high costs that excluded institutional long-term care from many families’ initial choices, a multi-level subsidy framework for service providers and families of older adults should be incorporated into the support system to bridge the payment gap and unleash effective demand; Meanwhile, efforts should be made to strengthen the external support networks of long-term care institutions, explore sustainable cooperation mechanisms between these institutions and other organizations based on substantial benefit sharing and enhance workforce development and career attractiveness.

Limitations of the study

This study adopted the service blueprint method to systematically visualize the entire process of health services for dementia in older adults, identify and analyze gaps and failure points in the current service chain, and propose optimization strategies. To achieve comprehensiveness, the research interviews covered various stakeholders, including service users and providers; however, several limitations remain. First, the sample did not include key social support network entities such as public welfare organizations, volunteers, and community workers. Second, failure points were mainly identified from the perspectives of patient-side and health service providers, and the exploration of obstacles in backstage behavior (such as hospital internal management processes) and support systems (such as policy makers and medical insurance departments) may be sufficient. Therefore, potential fault points at the line of visibility and the line of internal interaction were not prominently identified. Finally, the respondents were recruited only from Wuhan city, and medical insurance policies and resource allocation may differ from those in other regions. Therefore, the proposed integrated service model should be promoted with caution and tailored to specific local contexts. These limitations also suggest directions for future research, such as exploring the integration mechanism of social support networks in depth or validating the model in a broader r range of regions, to promote the construction of a more comprehensive integrated health service model for dementia in older adults.

Conclusion

This study used the service blueprint method to systematically visualize the entire process of health services for dementia in older adults, from prevention and screening through diagnosis and intervention to chronic management. It analyzed the current service failure points and core issues affecting service continuity and integrity, and proposed targeted countermeasures to provide a reference for building an integrated health service model. The findings suggest that building such a model requires prioritizing three core issues need to be prioritized: first, strengthening the service foundation by stabilizing financial and health insurance support, developing interdisciplinary workforce capacity, promoting equitable resources allocation, improving home-base service regulations, and implementing age friendly environmental adaptations, thereby reinforcing the “central nervous system” of the support system; second, establishing institutional collaboration to address fragmented service chains; and third, deepening engagement between service users and providers to establish more comprehensive communication and response mechanisms between service providers, patients, and their families.

Electronic Supplementary Material

Below is the link to the electronic supplementary material.

Author contributions

Tian Gan: Writing – Review & Editing, Writing – Original draft, Formal analysis, Visualization, Data curation. Hongyu Yan: Investigation, Review, Funding Acquisition, Resources. Yuzhi Gong: Investigation. Ling Ding: Investigation. Yanni Xie: Investigation. Chong Tian: Writing – Review & Editing, Supervision, Investigation， Funding Acquisition.

Funding

This study was funded by the Humanities and Social Sciences Foundation of the Ministry of Education of China (grant numbers 22YJC630126) and the Natural Science Foundation of Hubei Province (grant numbers 2025AFB713).

Data availability

The coding scheme and key quotes of participants necessary to support the results are included in the manuscript and supplementary material. Access to anonymized versions of the interview transcripts can be granted upon reasonable request to the authors.

Declarations

Ethics approval and consent to participate

This study was approved by the Medical Ethics Committee of Tongji Medical College, Huazhong University of Science and Technology (Approval number: S906). All participants provided informed consent and verbally agreed to have the interview recorded. This study was conducted according to the guidelines of the Declaration of Helsinki.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.