As healthcare systems face increasing demands from aging populations and the prevalence of neurodegenerative diseases, there is a growing need for integrated, scalable digital solutions. This paper introduces a Digital Healthcare Reference Model (DHRM) developed to enable AI-supported diagnoses for dementia and frailty care. Grounded in Action Research, the model was iteratively constructed through the collaboration of clinical and technical experts. These approaches provided diverse real-world data on clinical workflows, user requirements and care strategies for improving the individuals’ well-being and quality of life (QoL). The DHRM formalizes core clinical workflows and defines key actors, data entities and system components, organizing them into a layered architecture that supports data ingestion, processing, decision support, and user interaction. The model bridges clinical practice and technical design, enabling consistent integration of AI-based tools into routine care. By establishing a reusable framework for digital health systems, this work contributes to the development of standardized, explainable and adaptable infrastructures for managing complex, age-related health conditions.