Integrating Primary and Community-Based Care for Hypertension and Diabetes: A Scoping Review and Implementation Framework

Background Asia is experiencing a rapid rise in multimorbidity, driven by population ageing and lifestyle transitions. Hypertension and diabetes are now the leading contributors to cardiovascular morbidity, yet health-system responses remain fragmented. Integration of primary health care (PHC) with community-based services has been proposed as a strategy to strengthen continuity of care and reduce inequities. Methods We conducted a scoping review of peer-reviewed and grey literature published between 2013 and 2025 in PubMed, Embase, Scopus, and WHO regional databases. Eligible studies described interventions that linked PHC with community-based or non-clinical components for adults with hypertension and/or diabetes in Asia-Pacific countries. Data were extracted on setting, intervention components, workforce model, outcomes, and implementation barriers/facilitators. Findings were synthesised thematically and mapped against the WHO Health System Building Blocks and the Behaviour Change Wheel (BCW). Findings Fifty-seven studies from 14 countries met inclusion criteria. Integration models varied from community health-worker-led home visits (India, the Philippines) and nurse-driven chronic care teams (Thailand, China) to digital adherence and telemonitoring platforms (Singapore, South Korea). Successful programmes shared three attributes: (1) task-sharing between PHC providers and community actors; (2) structured feedback loops connecting community screening, referral, and follow-up; and (3) embedded behaviour-change supports targeting both patients and providers. Key barriers included financing silos, workforce turnover, weak health-information systems, and insufficient policy alignment. Based on synthesis, we propose the Integrated Primary and Community Care for Chronic Disease (IPACCD) Framework, articulating four domains (coordination, capacity, communication, and community engagement) as mechanisms linking intervention inputs to sustained control of blood pressure and glucose. Interpretation Integrated primary-community care can improve chronic disease outcomes in Asia-Pacific contexts if implemented through adaptive, system-wide strategies. The IPACCD framework offers a pragmatic guide for governments and implementers to design, scale, and evaluate integrated care for multimorbidity.