Wang,X,et al.The Luohu Model:A Template for Integrated Urban mesd18 Healthcare Systems in China.International Journal of Integrated Care2018;18(4):3,1-10.DOl:https:/1doi.org/10.5334/jic.3955 POLICY PAPER The Luohu Model:A Template for Integrated Urban Healthcare Systems in China Xin Wang,Xizhuo Sunt,Fangfang Gongt,Yixiang Huang,Lijin Chen', Yong Zhang'and Stephen Bircht Introduction:Emerging from the epidemiological transition and accelerated aging process,China's fragmentated healthcare systems struggle to meet the demands of the population.On Sept 1st 2017, China's National Health and Family Planning Commission encouraged all cities to learn from the Luohu model of integration adopted in Luohu as an approach to meeting these challenges.In this paper,we study the integration process,analyze the core mechanisms,and conduct preliminary evaluations of integrated policy development in the Luohu model. Policy development:The Luohu hospital group was established in Aug 2015,consists of five district hospitals,23 community health stations and an institute of precision medicine.The group adopted a series of professional,organizational,system,functional and normative strategies for integrated care, which was provided for the residents of Luohu,especially for the elderly population and patients with chronic conditions.According to a preliminary evaluation of the past two years,the Luohu model showed improvement in the structure and process towards integrated care.New preventive programs conducted in the hospital group resulted in changes of disease incidence.Residents were more satisfied with the Luohu model.However,spending exceeded the global budget for health insurance because of short-term increases in the demand for health care. Lessons learned:First,engagement of multiple stakeholders is essential for the design and implementa- tion of reform.Second,organizational integration is a prerequisite for integrated care in China.Third, effective care integration requires alignment with payment reforms.Fourth,normative integration could promote collaboration in an integrated healthcare system. Conclusion:Core strategies and mechanisms of the Luohu model will promote integrated care in urban China and other countries facing the same challenges.However,it is necessary to study the effects of the Luohu model over the long term and continue to strive for integrated care. Keywords:integrated care;hospital group;district healthcare system Introduction efficiency,cost escalation,and poor patient experiences Healthcare systems worldwide have been designed pri-[6,7].As a developing country getting old before getting marily to deal with single,acute,and short-term illnesses rich,China's healthcare systems are facing considerable [1,2].However,emerging from the epidemiological tran-challenges of fragmented care.In China,there were 231 sition and an accelerated population aging process,frag- million people aged 60 years or over in China(16.7%of mentated healthcare provided by traditional healthcare the population)[8]in 2016.Among them,more than 100 systems in most countries cannot meet the demands of million had at least one chronic noncommunicable dis- the population,especially the elderly,many of whom ease [9].Further,626 deaths,21,020 disability adjusted often have chronic diseases 3-5.Moreover,the tradi- of life years(DALY)and 8,879 years lived with disability tional healthcare system has suffered from low levels of (YLDS)per 100,000 population were attributed to chronic noncommunicable disease [10].It is predicted that the percentage of people aged 60 or over will increase from School of Public Health,Health Development Research Center, 12.4%in 2010 to 28%in 2040 [11].These challenges Sun Yat-sen University,74 Zhongshan 2nd Road, Guangzhou,CN indicate a need for urgency in transition from fragmented t Shenzhen Luohu Hospital Group,No.47 Youyi Road, care to integrated care in China's healthcare systems. Shenzhen,CN Current fragmented healthcare delivery in China is hos- Centre for the Business and Economics of Health,University pital-centered and treatment-dominated,with little effec- of Queensland,AU tive collaboration among institutions in different tiers of Corresponding author:Yixiang Huang (huangyx@mail.sysu.edu.cn) the system [12].In the 1980s,China moved to a market
Introduction Healthcare systems worldwide have been designed primarily to deal with single, acute, and short-term illnesses [1, 2]. However, emerging from the epidemiological transition and an accelerated population aging process, fragmentated healthcare provided by traditional healthcare systems in most countries cannot meet the demands of the population, especially the elderly, many of whom often have chronic diseases [3–5]. Moreover, the traditional healthcare system has suffered from low levels of efficiency, cost escalation, and poor patient experiences [6, 7]. As a developing country getting old before getting rich, China’s healthcare systems are facing considerable challenges of fragmented care. In China, there were 231 million people aged 60 years or over in China (16.7% of the population) [8] in 2016. Among them, more than 100 million had at least one chronic noncommunicable disease [9]. Further, 626 deaths, 21,020 disability adjusted of life years (DALY) and 8,879 years lived with disability (YLDS) per 100,000 population were attributed to chronic noncommunicable disease [10]. It is predicted that the percentage of people aged 60 or over will increase from 12.4% in 2010 to 28% in 2040 [11]. These challenges indicate a need for urgency in transition from fragmented care to integrated care in China’s healthcare systems. Current fragmented healthcare delivery in China is hospital-centered and treatment-dominated, with little effective collaboration among institutions in different tiers of the system [12]. In the 1980s, China moved to a market POLICY PAPER The Luohu Model: A Template for Integrated Urban Healthcare Systems in China Xin Wang* , Xizhuo Sun† , Fangfang Gong† , Yixiang Huang* , Lijin Chen* , Yong Zhang* and Stephen Birch‡ Introduction: Emerging from the epidemiological transition and accelerated aging process, China’s fragmentated healthcare systems struggle to meet the demands of the population. On Sept 1st 2017, China’s National Health and Family Planning Commission encouraged all cities to learn from the Luohu model of integration adopted in Luohu as an approach to meeting these challenges. In this paper, we study the integration process, analyze the core mechanisms, and conduct preliminary evaluations of integrated policy development in the Luohu model. Policy development: The Luohu hospital group was established in Aug 2015, consists of five district hospitals, 23 community health stations and an institute of precision medicine. The group adopted a series of professional, organizational, system, functional and normative strategies for integrated care, which was provided for the residents of Luohu, especially for the elderly population and patients with chronic conditions. According to a preliminary evaluation of the past two years, the Luohu model showed improvement in the structure and process towards integrated care. New preventive programs conducted in the hospital group resulted in changes of disease incidence. Residents were more satisfied with the Luohu model. However, spending exceeded the global budget for health insurance because of short-term increases in the demand for health care. Lessons learned: First, engagement of multiple stakeholders is essential for the design and implementation of reform. Second, organizational integration is a prerequisite for integrated care in China. Third, effective care integration requires alignment with payment reforms. Fourth, normative integration could promote collaboration in an integrated healthcare system. Conclusion: Core strategies and mechanisms of the Luohu model will promote integrated care in urban China and other countries facing the same challenges. However, it is necessary to study the effects of the Luohu model over the long term and continue to strive for integrated care. Keywords: integrated care; hospital group; district healthcare system * School of Public Health, Health Development Research Center, Sun Yat-sen University, 74 Zhongshan 2nd Road, Guangzhou, CN † Shenzhen Luohu Hospital Group, No. 47 Youyi Road, Shenzhen, CN ‡ Centre for the Business and Economics of Health, University of Queensland, AU Corresponding author: Yixiang Huang (huangyx@mail.sysu.edu.cn) Wang, X, et al. The Luohu Model: A Template for Integrated Urban Healthcare Systems in China. International Journal of Integrated Care, 2018; 18(4): 3, 1–10. DOI: https://doi.org/10.5334/ijic.3955
Art.3,page 2 of 10 Wang et al:The Luohu Model economy,and the government dramatically reduced hospi- tricts in Shenzhen,with an area of 78.36 km2 and a popu- tal funding.Responding to these reductions,hospitals tried lation of 1.4 million.Per capital Gross Domestic Product to earn revenues by providing more profitable health care (GDP)in Luohu was $25,200 in 2016 [23].It also has the primarily diagnosis and treatment rather than prevention largest proportion of the elderly residents in Shenzhen. and rehabilitation.The traditional three-tier healthcare sys It is estimated that the number of elderly individuals and tem collapsed,and primary health care stations no longer patients with chronic conditions exceeds over 451,000. served as gatekeepers 13.Since new health reforms were The government of Luohu has the tradition of reform,not introduced in 2009,China's government has been encour- only in economy but also in health. aging health care provision in primary health stations by Luohu District has five district-level hospitals and 83 financial subsidies and a program entitled Equalization of community health stations.While most cities with two- Basic Public Health Services [14.However,measures to level primary health care institutions [24].Luohu has improve collaboration among institutions and reduce frag- only one-level community health stations.Furthermore, mentation of services have been insufficient. all 83 community health stations are affiliated with one Over the last decade,integrated care has been sug- of the five hospitals.For example,the community health gested as one strategy for promoting coordinated health management center in the Luohu General Hospital is care delivery,improving the quality of care and reduc- in charge of 18 community health stations,managing ing costs [15-17].In 2016,the report "Deepening health human resources,finance,assets and service delivery in reform in China"[18].published by the World Health each station.Also located in Luohu is a city-level gen- Organization(WHO),World Bank(WB),and the Chinese eral hospital with 2,000 beds,under the charge of the Government,proposed strengthening healthcare in China Shenzhen city government.The numbers of beds and through a tiered health care delivery system in accord- physicians in the city hospital exceed those in the five ance with a People-Centered Integrated Care model.In independent district hospitals.The expansion of the April 2017,the General Office of the State Council issued a city hospital has been associated with the weakening of Guideline for constructing Medical Consortia [19].In the the ability of district hospitals and community health guideline,four types of medical consortia were suggested: stations to provide care as patients are free to seek ser hospital groups in urban areas,medical associations in vices at the city hospital directly.Therefore,"line up for rural areas,cross-regional specialist alliances and tele- 3 hours,treatment for 3 minutes"became a problem collaboration networks in remote areas.Medical consortia in Luohu,especially for the elderly and patients with thus became a main means for achieving People-Centered chronic diseases.The Luohu health reform system aims Integrated Care.On Sept 1st 2017,China's National Health to achieve "less illness,fewer hospital admissions,lower and Family Planning Commission introduced the Luohu financial burdens,and better services"25 by develop- model,an approach to healthcare integration pioneered ment of a community-based and prevention-oriented in Luohu District,to the entire country and encouraged integrated care system. all cities to learn from it [20].Subsequently,more than 1,500 policy makers from health and other social sectors Process of the Luohu reform in 321 cities received on-site training in the Luohu model. Figure 1 shows the timeline of the Luohu reform.In The aims of this study are to introduce the Luohu model, February 2015,the district government began with the to evaluate its effects and to explore lessons learned.With concept "Shifting focus from treatment to health".After enhancement of the Belt and Road health collaboration 10 rounds of expert consultations,the Luohu hospital [21,22],health reforms in urban China may have a con- group was established in Aug 2015.It consists of five siderable impact on other countries'health systems,espe- district hospitals,23 community health stations,and an cially low-and-middle-income countries facing the same institute of precision medicine,along with six resource challenges.Moreover,features of healthcare integration sharing centers and six administrative centers(Figure 2). in China,which may differ from those in European coun After being established,the hospital group adopted a tries,may provide references for other countries. series of reforms.In Dec 2015,a Quality Management Center took action to improve the quality of care in all Development of the Luohu Model institutions,especially in community health stations.In Background of Shenzhen City and the Luohu District May 2016,a new health insurance policy,"Global budget, China's Reform and Opening in 1980s began in Shenzhen balance retained",was introduced which funded hospitals City,which,in 2016,ranked first in economic competitive- via global budgets and allowed institutions to retain any ness among cities nationwide.Luohu is one of the ten dis- funds not spent during the financial year.At the same Figure 1:Timeline of the Luohu reform
Art. 3, page 2 of 10 Wang et al: The Luohu Model economy, and the government dramatically reduced hospital funding. Responding to these reductions, hospitals tried to earn revenues by providing more profitable health care, primarily diagnosis and treatment rather than prevention and rehabilitation. The traditional three-tier healthcare system collapsed, and primary health care stations no longer served as gatekeepers [13]. Since new health reforms were introduced in 2009, China’s government has been encouraging health care provision in primary health stations by financial subsidies and a program entitled Equalization of Basic Public Health Services [14]. However, measures to improve collaboration among institutions and reduce fragmentation of services have been insufficient. Over the last decade, integrated care has been suggested as one strategy for promoting coordinated health care delivery, improving the quality of care and reducing costs [15–17]. In 2016, the report “Deepening health reform in China” [18], published by the World Health Organization (WHO), World Bank (WB), and the Chinese Government, proposed strengthening healthcare in China through a tiered health care delivery system in accordance with a People-Centered Integrated Care model. In April 2017, the General Office of the State Council issued a Guideline for constructing Medical Consortia [19]. In the guideline, four types of medical consortia were suggested: hospital groups in urban areas, medical associations in rural areas, cross-regional specialist alliances and telecollaboration networks in remote areas. Medical consortia thus became a main means for achieving People-Centered Integrated Care. On Sept 1st 2017, China’s National Health and Family Planning Commission introduced the Luohu model, an approach to healthcare integration pioneered in Luohu District, to the entire country and encouraged all cities to learn from it [20]. Subsequently, more than 1,500 policy makers from health and other social sectors in 321 cities received on-site training in the Luohu model. The aims of this study are to introduce the Luohu model, to evaluate its effects and to explore lessons learned. With enhancement of the Belt and Road health collaboration [21, 22], health reforms in urban China may have a considerable impact on other countries’ health systems, especially low- and-middle-income countries facing the same challenges. Moreover, features of healthcare integration in China, which may differ from those in European countries, may provide references for other countries. Development of the Luohu Model Background of Shenzhen City and the Luohu District China’s Reform and Opening in 1980s began in Shenzhen City, which, in 2016, ranked first in economic competitiveness among cities nationwide. Luohu is one of the ten districts in Shenzhen, with an area of 78.36 km2 and a population of 1.4 million. Per capital Gross Domestic Product (GDP) in Luohu was $25,200 in 2016 [23]. It also has the largest proportion of the elderly residents in Shenzhen. It is estimated that the number of elderly individuals and patients with chronic conditions exceeds over 451,000. The government of Luohu has the tradition of reform, not only in economy but also in health. Luohu District has five district-level hospitals and 83 community health stations. While most cities with twolevel primary health care institutions [24], Luohu has only one-level community health stations. Furthermore, all 83 community health stations are affiliated with one of the five hospitals. For example, the community health management center in the Luohu General Hospital is in charge of 18 community health stations, managing human resources, finance, assets and service delivery in each station. Also located in Luohu is a city-level general hospital with 2,000 beds, under the charge of the Shenzhen city government. The numbers of beds and physicians in the city hospital exceed those in the five independent district hospitals. The expansion of the city hospital has been associated with the weakening of the ability of district hospitals and community health stations to provide care as patients are free to seek services at the city hospital directly. Therefore, “line up for 3 hours, treatment for 3 minutes” became a problem in Luohu, especially for the elderly and patients with chronic diseases. The Luohu health reform system aims to achieve “less illness, fewer hospital admissions, lower financial burdens, and better services” [25] by development of a community-based and prevention-oriented integrated care system. Process of the Luohu reform Figure 1 shows the timeline of the Luohu reform. In February 2015, the district government began with the concept “Shifting focus from treatment to health”. After 10 rounds of expert consultations, the Luohu hospital group was established in Aug 2015. It consists of five district hospitals, 23 community health stations, and an institute of precision medicine, along with six resource sharing centers and six administrative centers (Figure 2). After being established, the hospital group adopted a series of reforms. In Dec 2015, a Quality Management Center took action to improve the quality of care in all institutions, especially in community health stations. In May 2016, a new health insurance policy, “Global budget, balance retained”, was introduced which funded hospitals via global budgets and allowed institutions to retain any funds not spent during the financial year. At the same Figure 1: Timeline of the Luohu reform
Wang et al:The Luohu Model Art.3,page 3 of 10 time,salary reform was instituted to motivate staff.In Strategies of the Luohu model Sept 2016,a prescription of three month was allowed Based on the Rainbow Model of integrated care developed for patients with one of ten types of chronic conditions by Valentijn and colleagues [26,27],integration pro- to seek treatment,to avoid unnecessary outpatient vis- cesses at the macro-level (system integration),meso-level its to district hospitals.In Nov 2016,the hospital group (organizational and professional integration).micro- encouraged specialists in district hospitals to set up clinics level (clinical integration)and cross-level (functional and in community health stations,to increase the proportion normative integration)contribute to integrated care.The of first contacts occurring in primary health stations.In strategies taken in Luohu for constructing a community- July 2017,the charter of the hospital group was amended based and prevention-oriented integrated care system are based on lessons learned from the preceding two years. summarized in Figure 3.There are strategies regarding Thus,the establishment of the hospital group provided professional,organizational,system,functional and nor- the basis for the ensuring reforms. mative integration.Among these are three core strategies Supervisory Board Expert Committee Workers'Congress Luohu hospital group Party Committee President Accountant 5 hospitals ces 6administrative 23 nters health Figure 2:Organizational structure of the Luohu hospital group. 1.1 Multidisciplinary family doctor teams Professional 2.1 Close hospital group integration 5 1 Shared vision in the hospital group (including five hospitals.one research 5.2 Build trust between residents institute.six health resources sharing centers. six administrative centers.twenty-three CHSe) and family doctor toams 2 Organizational Normative integration People- integration centered 3 Systom Functional integration integration 3.1 Global budget,balance retention 4.1 Platform for two-way referrals 3.2 Six administrative centers 4.2 Health Luohu APP and 4G 3.3 Six resources-sharing centers mobile nursing Figure 3:Strategies for an integrated care system in Luohu
Wang et al: The Luohu Model Art. 3, page 3 of 10 time, salary reform was instituted to motivate staff. In Sept 2016, a prescription of three month was allowed for patients with one of ten types of chronic conditions to seek treatment, to avoid unnecessary outpatient visits to district hospitals. In Nov 2016, the hospital group encouraged specialists in district hospitals to set up clinics in community health stations, to increase the proportion of first contacts occurring in primary health stations. In July 2017, the charter of the hospital group was amended based on lessons learned from the preceding two years. Thus, the establishment of the hospital group provided the basis for the ensuring reforms. Strategies of the Luohu model Based on the Rainbow Model of integrated care developed by Valentijn and colleagues [26, 27], integration processes at the macro-level (system integration), meso-level (organizational and professional integration), microlevel (clinical integration) and cross-level (functional and normative integration) contribute to integrated care. The strategies taken in Luohu for constructing a communitybased and prevention-oriented integrated care system are summarized in Figure 3. There are strategies regarding professional, organizational, system, functional and normative integration. Among these are three core strategies Figure 2: Organizational structure of the Luohu hospital group. Figure 3: Strategies for an integrated care system in Luohu
Art.3,page4 of 10 Wang et al:The Luohu Model for establishment of the hospital group.In the hospital paid by the group.To avoid physicians'reducing services group.Detailed integrated care was provided for the resi- to increase the balance of health insurance,the quality dents,especially for the elderly and patients with chronic management center is responsible for supervising physi- conditions. cians'practices. The third strategy involved building family doctor teams Three core strategies in each community health station.Family doctor teams The first strategy was the establishment of a hospital group play an important role in promoting effective resource in the form of an independent corporation.Six resource utilization,reducing costs and improving patient sat- sharing centers were organized using the resources of the isfaction [28.However,a dearth of general practition- respective centers in the former five hospitals,including a ers hindered the development of family doctor teams in medical testing center,a radiographic center,an informa- China[29].The Luohu hospital group recruited general tion center,a health management center,a logistics and practitioners throughout the world,hired international distribution center and a disinfection and supply center, general practitioner experts for on-site clinical train- along with six administrative centers to manage all insti- ing and encouraged position shifts for some specialists. tutions in the group,including a human resource center,a In community health stations,each family doctor team financial center,a quality management center,a research consists of a general practitioner (leader),nurses,health and education center,a community health station man- promotion staff and a public health physician and may agement center and an integrated management center. also include specialists,pharmacists,nutritionists,and Twelve centers provide resources and management for psychologists.Specialists are provided with an incentive the entire hospital group.After the organizational inte- of $100 per day to set up clinics in the community health gration,there were 1,172 beds,3,479 staff,and 778 stations or serve as a member of a family doctor team in physicians in the group.The president is responsible for community health stations in their spare time.A list of the group under the leadership of a council.Among 12 ten identified tasks of the family doctor team (including council members,there are policy makers from the Dis- health education,case management for pregnant women trict Government,Health and Family Planning Commis- etc.)was widely publicized to make residents understand sion and resident representatives.The president has the the team's responsibilities.The family doctor team was capacity to make plans and coordinate activities for all expected to change the behavior of staff in community institutions in the group.All institutions in the group health stations and provide a platform for the transition share management,services,benefits and responsibilities from hospital-centered treatment-dominated care to com- The second strategy was the development of a new munity-based prevention-first care. health insurance policy,"Global budget,balance retained". Shenzhen's Social Insurance Fund Administration,which Integrated care for the elderly is affiliated with the Human Resources and Social Security In Aug 2014,a Rehabilitation Center for the elderly was Bureau,is responsible for collecting and managing the introduced by the general district hospital in Luohu and social insurance fund of the entire city.Coordinated by began to explore integrated care for the elderly [301.After Shenzhen's Health and Family Planning Commission, the establishment of the Luohu hospital group,an inte- Luohu became the first pilot for this new health insur- grated care system for the elderly was formed based on ance policy.The global budget of the hospital group in home care and community care supplemented by hospi- 2016 was given by the total cost of health insurance for talization. registered residents in the previous year multiplied by the Home care.Staff in community health stations provide average growth rate of the health insurance fund in 2016. nursing,rehabilitation,and palliative care for the disa- It should be noted that registered residents could seek bled elderly by setting up beds in the patients'homes.The health care in any institutions inside or outside the hos District's Ministry of Finance provides a subsidy for home pital group.Wherever the residents received health care, care.Community care delivery varies between communi- the hospital group had to pay for them,unlike a Health ties.First,through collaboration with community health Maintenance Organizations model where the organization stations,day care centers in the community provide drug is only accountable for care provided within the organiza- management,rehabilitation and health education for tion.Any surplus at the end of the year is retained and the elderly.Second,day care centers affiliated with hos- can be used for staff bonuses.The incentive and restraint pitals provide treatment,nursing,rehabilitation,and mechanisms formed by this policy aimed to change the case management for the elderly using multi-profession behavior of district hospitals.On the one hand,hospitals teams.Third,social service centers inside each commu- have to pay more attention to helping community health nity health station provide integrated care for the elderly. stations provide prevention and case management.Only Hospitalization care.The geriatric hospital in the hospital in this way can they reduce illnesses and the demand for group provides not only nursing and rehabilitation services hospitalization and hence reduce the health insurance but also diagnostic and treatment services for the elderly. cost of the group.On the other hand,hospitals will make efforts to improve the quality of health services and gain Integrated care for patients with chronic conditions the residents'trust to avoid patients seeking health ser- The Luohu hospital group explored integrated care and vices outside the group.The cost for registered patients case management for patients with chronic diseases. seeking treatment in hospitals outside the group will be Public health physicians were allocated to community
Art. 3, page 4 of 10 Wang et al: The Luohu Model for establishment of the hospital group. In the hospital group. Detailed integrated care was provided for the residents, especially for the elderly and patients with chronic conditions. Three core strategies The first strategy was the establishment of a hospital group in the form of an independent corporation. Six resourcesharing centers were organized using the resources of the respective centers in the former five hospitals, including a medical testing center, a radiographic center, an information center, a health management center, a logistics and distribution center and a disinfection and supply center, along with six administrative centers to manage all institutions in the group, including a human resource center, a financial center, a quality management center, a research and education center, a community health station management center and an integrated management center. Twelve centers provide resources and management for the entire hospital group. After the organizational integration, there were 1,172 beds, 3,479 staff, and 778 physicians in the group. The president is responsible for the group under the leadership of a council. Among 12 council members, there are policy makers from the District Government, Health and Family Planning Commission and resident representatives. The president has the capacity to make plans and coordinate activities for all institutions in the group. All institutions in the group share management, services, benefits and responsibilities. The second strategy was the development of a new health insurance policy, “Global budget, balance retained”. Shenzhen’s Social Insurance Fund Administration, which is affiliated with the Human Resources and Social Security Bureau, is responsible for collecting and managing the social insurance fund of the entire city. Coordinated by Shenzhen’s Health and Family Planning Commission, Luohu became the first pilot for this new health insurance policy. The global budget of the hospital group in 2016 was given by the total cost of health insurance for registered residents in the previous year multiplied by the average growth rate of the health insurance fund in 2016. It should be noted that registered residents could seek health care in any institutions inside or outside the hospital group. Wherever the residents received health care, the hospital group had to pay for them, unlike a Health Maintenance Organizations model where the organization is only accountable for care provided within the organization. Any surplus at the end of the year is retained and can be used for staff bonuses. The incentive and restraint mechanisms formed by this policy aimed to change the behavior of district hospitals. On the one hand, hospitals have to pay more attention to helping community health stations provide prevention and case management. Only in this way can they reduce illnesses and the demand for hospitalization and hence reduce the health insurance cost of the group. On the other hand, hospitals will make efforts to improve the quality of health services and gain the residents’ trust to avoid patients seeking health services outside the group. The cost for registered patients seeking treatment in hospitals outside the group will be paid by the group. To avoid physicians’ reducing services to increase the balance of health insurance, the quality management center is responsible for supervising physicians’ practices. The third strategy involved building family doctor teams in each community health station. Family doctor teams play an important role in promoting effective resource utilization, reducing costs and improving patient satisfaction [28]. However, a dearth of general practitioners hindered the development of family doctor teams in China [29]. The Luohu hospital group recruited general practitioners throughout the world, hired international general practitioner experts for on-site clinical training and encouraged position shifts for some specialists. In community health stations, each family doctor team consists of a general practitioner (leader), nurses, health promotion staff and a public health physician and may also include specialists, pharmacists, nutritionists, and psychologists. Specialists are provided with an incentive of $100 per day to set up clinics in the community health stations or serve as a member of a family doctor team in community health stations in their spare time. A list of ten identified tasks of the family doctor team (including health education, case management for pregnant women etc.) was widely publicized to make residents understand the team’s responsibilities. The family doctor team was expected to change the behavior of staff in community health stations and provide a platform for the transition from hospital-centered treatment-dominated care to community-based prevention-first care. Integrated care for the elderly In Aug 2014, a Rehabilitation Center for the elderly was introduced by the general district hospital in Luohu and began to explore integrated care for the elderly [30]. After the establishment of the Luohu hospital group, an integrated care system for the elderly was formed based on home care and community care supplemented by hospitalization. Home care. Staff in community health stations provide nursing, rehabilitation, and palliative care for the disabled elderly by setting up beds in the patients’ homes. The District’s Ministry of Finance provides a subsidy for home care. Community care delivery varies between communities. First, through collaboration with community health stations, day care centers in the community provide drug management, rehabilitation and health education for the elderly. Second, day care centers affiliated with hospitals provide treatment, nursing, rehabilitation, and case management for the elderly using multi-profession teams. Third, social service centers inside each community health station provide integrated care for the elderly. Hospitalization care. The geriatric hospital in the hospital group provides not only nursing and rehabilitation services but also diagnostic and treatment services for the elderly. Integrated care for patients with chronic conditions The Luohu hospital group explored integrated care and case management for patients with chronic diseases. Public health physicians were allocated to community
Wang et al:The Luohu Model Art.3,page5 of 10 health stations and became members of family doctor collaboration between district hospitals and community teams.Health care delivery for patients with chronic health stations promoted patient referral in the hospital diseases changed from treatment-dominated to preven- group.No patient was referred from hospitals to commu- tion-first based on three strategies. nity health stations for follow-up or rehabilitation services First,the group paid more attention to preventive care. in 2015,but in 2016 over 10,000 patients were referred For example,regular lectures were given in each commu- from hospitals in the group to community health stations nity and a Healthy Luohu app was designed for improving to receive the right care at the right place. residents'health literacy.In cooperation with the govern- Outcome evaluation.During the past two years,4,596 ment,the group helped to construct two jogging trails for more patients with diabetes,4,995 more patients with residents,to cultivate exercise.Moreover,free pneumonia hypertension and 822 more patients with severe mental vaccinations were provided for those over 60 years of age illness were enrolled in case management (Table 1). in2016. Compared with Jun 2014-Dec 2015,there were more new Second,the group introduced screening programs for cancer cases per month identified during Jun 2015-Jun diseases with high morbidity and mortality,with particu- 2016.There was a decrease in pneumonia cases in the lar focus on cancers.Screening programs for breast cancer, second year after reform.Residents'satisfaction with com- cervical cancer,lung cancer,liver cancer,and gastrointes- munity health stations in Luohu ranked first among the tinal cancer were introduced [24],to support early diag- ten districts of Shenzhen in 2015 and 2016.However,the nosis and treatment. mean cost per resident of all types of health care increased Third,physicians prepared individualized healthcare fom$675.3to$844.2. plans for patients and provided medical treatment and non-drug guidance regularly in collaboration with general Discussion practitioners.There is a Referral Gateway between general Stakeholders pushing the reform practitioners in community health stations and hospi- The District government of Luohu gave priority to health, tals in the group.Whenever patients need the services and set the direction for the reform by 'shifting focus from of specialists,physicians will refer them to one of the treatment to health".The District government helped the group's hospitals and continue to follow up. District Health and Family Planning Commission to coor- dinate with the Ministry of Finance,Human Resources and Evaluation of the Luohu model Social Security Bureau and Social Insurance Fund Admin- Framework istration,to ensure that supporting measures would be in Devers and colleagues [31]suggested that healthcare place.Further,the District government increased financial integration be evaluated in three dimensions:readiness subsidies to the group,especially community health sta- of integration(structure),internal process of integration tions.In 2016,the Ministry of Finance invested $112 mil- (process),and outcomes of integration (outcome).Selec- lion (accounting for 27.2%of all health expenditures in tion of the second-and third-level indicators was based the district)in the group. on a review of the literature,as well as on the aims of and Staff in the group contributed efforts to the reform. programs in the Luohu model.In this study,we adopted Physicians and nurses adopted a philosophy of serving six indicators to evaluate "structure",eight indicators patients,improving treatment capacity,and strengthen- system to evaluate "process"and 12 indicators to evaluate ing collaboration with team members.Meanwhile,the outcome"(Table 1). reform of salary payments enhanced the enthusiasm of all staff in the group. Results of evaluation Along with staff in the hospital group,residents helped Structure evaluation.In respect of infrastructure,the busi- create and share processes and outcomes of the reform. ness area of community health stations increased from Only by placing residents at the center of the system could 410m2 in Jun 2015 to 903m2 in Jun 2017.The assets the hospital group set the goal of constructing an inte- value of equipment across all community health stations grated care system.Before the reform,patients regarded increased from $2.73 million in Jun 2015 to $4.04 million the community health station as the last choice for service in Jun 2017.The number of general practitioner doubled. because they did not trust the quality of services available The number of public health physician increased from there.Now,42.6%residents regard community health sta- 2 to 30,while 49 specialists set up clinics in community tions as the first contact for health care.Overall,demands health stations,and 238 family doctor teams were devel- of residents have been driving the reform. oped during the same period. Process evaluation.By June 2017,580,000 residents had Strategies for integrated care been registered with general practitioners in the hospi- Some European projects have suggested that organizational tal group.The proportion of all hospitalizations going integration alone is unlikely to deliver better outcomes, to the group hospitals increased,which reduced the cost and that efforts must focus on clinical and service integra- of health insurance in the whole hospital group.In the tion.Other researchers have suggested that effective care group.The proportion of outpatient visits in community coordination can be achieved without the need for the for- health stations increase from 29.49%to 42.60%.This is a mal integration of organizations [32,33].Different from promising indicator that community health stations are most international experience,most pilot programs [34, acting for gatekeeper of the hospital group.Meanwhile, 35 in China mostly began with organizational integration
Wang et al: The Luohu Model Art. 3, page 5 of 10 health stations and became members of family doctor teams. Health care delivery for patients with chronic diseases changed from treatment-dominated to prevention-first based on three strategies. First, the group paid more attention to preventive care. For example, regular lectures were given in each community and a Healthy Luohu app was designed for improving residents’ health literacy. In cooperation with the government, the group helped to construct two jogging trails for residents, to cultivate exercise. Moreover, free pneumonia vaccinations were provided for those over 60 years of age in 2016. Second, the group introduced screening programs for diseases with high morbidity and mortality, with particular focus on cancers. Screening programs for breast cancer, cervical cancer, lung cancer, liver cancer, and gastrointestinal cancer were introduced [24], to support early diagnosis and treatment. Third, physicians prepared individualized healthcare plans for patients and provided medical treatment and non-drug guidance regularly in collaboration with general practitioners. There is a Referral Gateway between general practitioners in community health stations and hospitals in the group. Whenever patients need the services of specialists, physicians will refer them to one of the group’s hospitals and continue to follow up. Evaluation of the Luohu model Framework Devers and colleagues [31] suggested that healthcare integration be evaluated in three dimensions: readiness of integration (structure), internal process of integration (process), and outcomes of integration (outcome). Selection of the second- and third-level indicators was based on a review of the literature, as well as on the aims of and programs in the Luohu model. In this study, we adopted six indicators to evaluate “structure”, eight indicators system to evaluate “process” and 12 indicators to evaluate “outcome” (Table 1). Results of evaluation Structure evaluation. In respect of infrastructure, the business area of community health stations increased from 410m2 in Jun 2015 to 903m2 in Jun 2017. The assets value of equipment across all community health stations increased from $2.73 million in Jun 2015 to $4.04 million in Jun 2017. The number of general practitioner doubled. The number of public health physician increased from 2 to 30, while 49 specialists set up clinics in community health stations, and 238 family doctor teams were developed during the same period. Process evaluation. By June 2017, 580,000 residents had been registered with general practitioners in the hospital group. The proportion of all hospitalizations going to the group hospitals increased, which reduced the cost of health insurance in the whole hospital group. In the group. The proportion of outpatient visits in community health stations increase from 29.49% to 42.60%. This is a promising indicator that community health stations are acting for gatekeeper of the hospital group. Meanwhile, collaboration between district hospitals and community health stations promoted patient referral in the hospital group. No patient was referred from hospitals to community health stations for follow-up or rehabilitation services in 2015, but in 2016 over 10,000 patients were referred from hospitals in the group to community health stations to receive the right care at the right place. Outcome evaluation. During the past two years, 4,596 more patients with diabetes, 4,995 more patients with hypertension and 822 more patients with severe mental illness were enrolled in case management (Table 1). Compared with Jun 2014–Dec 2015, there were more new cancer cases per month identified during Jun 2015–Jun 2016. There was a decrease in pneumonia cases in the second year after reform. Residents’ satisfaction with community health stations in Luohu ranked first among the ten districts of Shenzhen in 2015 and 2016. However, the mean cost per resident of all types of health care increased from $675.3 to $844.2. Discussion Stakeholders pushing the reform The District government of Luohu gave priority to health, and set the direction for the reform by “shifting focus from treatment to health”. The District government helped the District Health and Family Planning Commission to coordinate with the Ministry of Finance, Human Resources and Social Security Bureau and Social Insurance Fund Administration, to ensure that supporting measures would be in place. Further, the District government increased financial subsidies to the group, especially community health stations. In 2016, the Ministry of Finance invested $112 million (accounting for 27.2% of all health expenditures in the district) in the group. Staff in the group contributed efforts to the reform. Physicians and nurses adopted a philosophy of serving patients, improving treatment capacity, and strengthening collaboration with team members. Meanwhile, the reform of salary payments enhanced the enthusiasm of all staff in the group. Along with staff in the hospital group, residents helped create and share processes and outcomes of the reform. Only by placing residents at the center of the system could the hospital group set the goal of constructing an integrated care system. Before the reform, patients regarded the community health station as the last choice for service, because they did not trust the quality of services available there. Now, 42.6% residents regard community health stations as the first contact for health care. Overall, demands of residents have been driving the reform. Strategies for integrated care Some European projects have suggested that organizational integration alone is unlikely to deliver better outcomes, and that efforts must focus on clinical and service integration. Other researchers have suggested that effective care coordination can be achieved without the need for the formal integration of organizations [32, 33]. Different from most international experience, most pilot programs [34, 35] in China mostly began with organizational integration