Policy practice People-centred integrated care in urban China Xin Wang,Xizhuo Sun,5 Stephen Birch,Fangfang Gong,Pim Valentijn,Lijin Chen,a Yong Zhang,? Yixiang Huang&Hongwei Yange Abstract In most countries,the demand for integrated care for people with chronic diseases is increasing as the population ages.This demand requires a fundamental shift of health-care systems towards more integrated service delivery models.To achieve this shift in China, the World Health Organization,the World Bank and the Chinese government proposed a tiered health-care delivery system in accordance with a people-centred integrated care model.The approach was pioneered in Luohu district of Shenzhen city from 2015 to 2017 as a template for practice.In September 2017,China's health ministry introduced this approach to people-centred integrated care to the entire country.We describe the features of the Luohu model in relation to the core action areas and implementation strategies proposed and we summarize data from an evaluation of the first two years of the programme.We discuss the challenges faced during implementation and the lessons learnt from it for other health-care systems.We consider how to improve collaboration between institutions,how to change the population's behaviour about using community health services as the first point of contact and how to manage resources effectively to avoid budget deficits.Finally,we outline next steps of the Luohu model and its potential application to strengthen health care in other urban health-care systems Abstracts in,Francais,PyccKn and Espanol at the end of each article. The World Health Organization (WHO)describes Introduction people-centred integrated care as health services that are On 1 September 2017,China's health ministry introduced a managed and delivered so that patients receive a continuum new approach to people-centred integrated care to the entire of preventive and curative services according to their needs over time that is coordinated across different levels of the country.'Called the Luohu model,the approach was pioneered in Luohu district of Shenzhen city.This development was a health-care system.Over the last decade,integrated response to the problems faced by the existing health-care care has been suggested as one strategy for promoting system in addressing the increased demands of delivering coordinated health-care delivery,improving quality of integrated care.Health-care systems worldwide are facing care and reducing costs.2 In 2016,the report Deepening similar problems emerging from epidemiological transition health reform in China was published jointly by the WHO, and population ageing.Many people-centred integrated the World Bank and the Chinese government.S The report care programmes have been initiated,implemented and evalu- proposed strengthening health care in China through a ated in high-income countries.While experience from other tiered health-care delivery system in accordance with a countries provides a useful basis for planning,the ability to people-centred integrated care model. The introduction of the Luohu model set an example for achieve people-centred integrated care can be highly context- specific and there is a lack of knowledge about how to stimu- urban areas in China to build people-centred integrated care late integrated care in low-and middle-income countries.0 delivery systems.This represented a big step in pursuing higher The current system of health-care delivery in China is quality health care,better outcomes and more affordable costs fragmented,hospital-centred and treatment-dominated,with for the population in China.In this paper,we describe the little effective collaboration among institutions in different features of the Luohu model,discuss lessons learnt from its tiers of the system.312 In 2016,there were an estimated 231 implementation and outline next steps for the Luohu model million people aged 60 years or older in China,16.7%of the and its application in other Chinese urban health-care systems. population of 1383 billion,and more than 100 million among We also provide suggestions on adapting the Luohu model in them had at least one chronic noncommunicable disease. other low-and middle-income countries. Predictions suggested that without health-care reform,China's health-care costs in United States dollars(US$)would increase The Luohu model from 5.6%of gross domestic product in 2015(USS 592 billion of US$10571 billion)to 9.1%in 2035(US$2713 billion of Background USS 29810 billion).'5 System reform was therefore viewed as The Luohu model was a response to the needs of patients and necessary to avoid the risk of becoming a high-cost,low-value their families in Luohu district(Health and Family Planning health-care system. Commission of Shenzhen city,unpublished data,2015).With School of Public Health,SUN Yat-sen University,No.74,Zhongshan 2nd Road,Yuexiu District,Guangzhou 510080,China Shenzhen Luohu Hospital Group,Shenzhen,China. Centre for the Business and Economics of Health,University of Queensland,Brisbane,Australia. dDepartment of Health Services Research,Care and Public Health Research Institute(CAPHRI),Faculty of Health,Medicine and Life Sciences,Maastricht University, Maastricht,Netherlands. China National Health Development Research Centre,Beijing,China Correspondence to Yixiang Huang (email:huangyx@mail sysu.edu.cn). (Submitted:22 April 2018-Revised version received:7 September 2018-Accepted:7 September 2018-Published online:1 October 2018) Bull World Health Organ 2018:96:843-852 doi:http://dx.doi.org/10.2471/BLT.18.214908 843
Bull World Health Organ 2018;96:843–852 | doi: http://dx.doi.org/10.2471/BLT.18.214908 Policy & practice 843 Introduction On 1 September 2017, China’s health ministry introduced a new approach to people-centred integrated care to the entire country.1 Called the Luohu model, the approach was pioneered in Luohu district of Shenzhen city. This development was a response to the problems faced by the existing health-care system in addressing the increased demands of delivering integrated care.2,3 Health-care systems worldwide are facing similar problems emerging from epidemiological transition and population ageing.4–6 Many people-centred integrated care programmes have been initiated, implemented and evaluated in high-income countries. While experience from other countries provides a useful basis for planning,7,8 the ability to achieve people-centred integrated care can be highly contextspecific8,9 and there is a lack of knowledge about how to stimulate integrated care in low- and middle-income countries.10 The current system of health-care delivery in China is fragmented, hospital-centred and treatment-dominated, with little effective collaboration among institutions in different tiers of the system.3,11,12 In 2016, there were an estimated 231 million people aged 60 years or older in China, 16.7% of the population of 1 383 billion, and more than 100 million among them had at least one chronic noncommunicable disease.13,14 Predictions suggested that without health-care reform, China’s health-care costs in United States dollars (US$) would increase from 5.6% of gross domestic product in 2015 (US$ 592 billion of US$ 10 571 billion) to 9.1% in 2035 (US$ 2713 billion of US$ 29 810 billion).15 System reform was therefore viewed as necessary to avoid the risk of becoming a high-cost, low-value health-care system. The World Health Organization (WHO) describes people-centred integrated care as health services that are managed and delivered so that patients receive a continuum of preventive and curative services according to their needs over time that is coordinated across different levels of the health-care system.16–19 Over the last decade, integrated care has been suggested as one strategy for promoting coordinated health-care delivery, improving quality of care and reducing costs.20,21 In 2016, the report Deepening health reform in China was published jointly by the WHO, the World Bank and the Chinese government.15 The report proposed strengthening health care in China through a tiered health-care delivery system in accordance with a people-centred integrated care model. The introduction of the Luohu model set an example for urban areas in China to build people-centred integrated care delivery systems. This represented a big step in pursuing higher quality health care, better outcomes and more affordable costs for the population in China. In this paper, we describe the features of the Luohu model, discuss lessons learnt from its implementation and outline next steps for the Luohu model and its application in other Chinese urban health-care systems. We also provide suggestions on adapting the Luohu model in other low- and middle-income countries. The Luohu model Background The Luohu model was a response to the needs of patients and their families in Luohu district (Health and Family Planning Commission of Shenzhen city, unpublished data, 2015). With Abstract In most countries, the demand for integrated care for people with chronic diseases is increasing as the population ages. This demand requires a fundamental shift of health-care systems towards more integrated service delivery models. To achieve this shift in China, the World Health Organization, the World Bank and the Chinese government proposed a tiered health-care delivery system in accordance with a people-centred integrated care model. The approach was pioneered in Luohu district of Shenzhen city from 2015 to 2017 as a template for practice. In September 2017, China’s health ministry introduced this approach to people-centred integrated care to the entire country. We describe the features of the Luohu model in relation to the core action areas and implementation strategies proposed and we summarize data from an evaluation of the first two years of the programme. We discuss the challenges faced during implementation and the lessons learnt from it for other health-care systems. We consider how to improve collaboration between institutions, how to change the population’s behaviour about using community health services as the first point of contact and how to manage resources effectively to avoid budget deficits. Finally, we outline next steps of the Luohu model and its potential application to strengthen health care in other urban health-care systems. a School of Public Health, SUN Yat-sen University, No. 74, Zhongshan 2nd Road, Yuexiu District, Guangzhou 510080, China. b Shenzhen Luohu Hospital Group, Shenzhen, China. c Centre for the Business and Economics of Health, University of Queensland, Brisbane, Australia. d Department of Health Services Research, Care and Public Health Research Institute (CAPHRI), Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, Netherlands. e China National Health Development Research Centre, Beijing, China. Correspondence to Yixiang Huang (email: huangyx@mail.sysu.edu.cn). (Submitted: 22 April 2018 – Revised version received: 7 September 2018 – Accepted: 7 September 2018 – Published online: 1 October 2018 ) People-centred integrated care in urban China Xin Wang,a Xizhuo Sun,b Stephen Birch,c Fangfang Gong,b Pim Valentijn,d Lijin Chen,a Yong Zhang,a Yixiang Huanga & Hongwei Yange Policy & practice
Policy practice People-centred care in urban China Xin Wang et al. a population of around 1.47 million in In February 2015,the Luohu gov- care to become the first point of an area of 78 km2,Luohu is the most ernment initiated a health-care reform contact;(ii)multidisciplinary teams; densely populated district ofShenzhen programme in cooperation with the lo- (iii)vertical integration;(iv)horizontal city,Guangdong province.In 2014,over cal ministries in Shenzhen (the Health integration;(v)eHealth;(vi)integrated 451000 people were estimated to live and Family Planning Commission,Min- clinical pathways and dual referral with chronic diseases in Luohu (Gong istry of Human Resources and Social systems;(vii)measurement and feed- F,Luohu hospital group,unpublished Security,and Ministry of Finance).The back;and (viii)certification and their data,2014).There was a city hospital stated goals of the Luohu people-centred accompanying strategies to achieve with 2000 beds,five district-level public integrated care model were better servic- people-centred integrated care.s The hospitals with a total of 1172 beds and es,less illness,fewer hospital admissions Luohu model implemented all the sug- 83 community health stations provid- and lower financial burdens.In August gested core actions except certification ing ambulatory care in the district.The 2015,an integrated organization -the (Table 1). growing size of the city hospital result- Luohu hospital group-was established, First,under the Luohu model,pa- ed in increasing numbers of patients at- comprising five district-level hospitals, tients are encouraged to sign a contract tending.Since patients had greater trust 23 community health stations and an in- with a general practitioner based at a in providers at the city-level hospital stitute of precision medicine.A council community health station and use him than the community health stations, composed of government officials and or her as the first point of contact with they often sought services directly at representatives from local communities the Luohu hospital group.However, the hospital despite receiving a lower managed the group with the support of the gatekeeping system is not manda- reimbursement of medical expenses. a local supervisory board,expert com- tory and allows an element of choice Furthermore,many patients stayed in mittee and workers'congress.The group for patients. hospital for post-acute care rather than established six resource-sharing centres Second,in community health sta- accessing this care in community health and six administrative centres (Fig.1) tions each primary health-care team stations,because city-and district-level by reorganizing the relevant centres of consists of essential members:a general hospitals and community health sta- the previous 29 institutions,to improve practitioner,a nurse,a public health tions operated independently and com- the efficiency of both resource use and physician and a health promotion peted for patients.The government of administration. practitioner.Teams may also include Shenzhen city and Luohu district were Actions and strategies a pharmacist,psychologist or other concerned about the unmet needs of specialist physician (e.g.geriatrician, the population and the increased health The policy report Deepening health paediatrician,internist)according to expenditure associated with inappro reform in China recommended eight the needs of local residents.General priate hospital use and lengths of stay. core action areas:(i)primary health practitioners lead in developing team Fig.1.Organizational structure of the Luohu hospital group,Shenzhen city,China Supervisory board Expert committee Manage Recall Council Luohu hospital group Workers'congress Party committee President Accountant 5 hospitals institute of 6 resource-sharing 6 administrative 23 community mediane centres centres health stations Traditional General Zhongxun Medical Human Chinese nospital precision testing centre Quality resources medicine medical Radiography management centre institute centre hospital centre Maternity and child Disinfection Financial health-care and supply centre Rehabilitation hospital Information centre Research and hospital centre education centre Community health Geriatric Health stations hospital Logistic and management General distribution centre management management centre centre centre 844 Bull World Hea/th Organ 2018;96:843-852 doi:http://dx.doi.org/10.2471/BLT.18.214908
844 Bull World Health Organ 2018;96:843–852| doi: http://dx.doi.org/10.2471/BLT.18.214908 Policy & practice People-centred care in urban China Xin Wang et al. a population of around 1.47 million in an area of 78 km2 , Luohu is the most densely populated district of Shenzhen city, Guangdong province. In 2014, over 451 000 people were estimated to live with chronic diseases in Luohu (Gong F, Luohu hospital group, unpublished data, 2014). There was a city hospital with 2000 beds, five district-level public hospitals with a total of 1172 beds and 83 community health stations providing ambulatory care in the district. The growing size of the city hospital resulted in increasing numbers of patients attending. Since patients had greater trust in providers at the city-level hospital than the community health stations, they often sought services directly at the hospital despite receiving a lower reimbursement of medical expenses. Furthermore, many patients stayed in hospital for post-acute care rather than accessing this care in community health stations, because city- and district-level hospitals and community health stations operated independently and competed for patients. The government of Shenzhen city and Luohu district were concerned about the unmet needs of the population and the increased health expenditure associated with inappropriate hospital use and lengths of stay. In February 2015, the Luohu government initiated a health-care reform programme in cooperation with the local ministries in Shenzhen (the Health and Family Planning Commission, Ministry of Human Resources and Social Security, and Ministry of Finance). The stated goals of the Luohu people-centred integrated care model were better services, less illness, fewer hospital admissions and lower financial burdens. In August 2015, an integrated organization – the Luohu hospital group – was established, comprising five district-level hospitals, 23 community health stations and an institute of precision medicine. A council composed of government officials and representatives from local communities managed the group with the support of a local supervisory board, expert committee and workers’ congress. The group established six resource-sharing centres and six administrative centres (Fig. 1) by reorganizing the relevant centres of the previous 29 institutions, to improve the efficiency of both resource use and administration. Actions and strategies The policy report Deepening health reform in China recommended eight core action areas: (i) primary health care to become the first point of contact; (ii) multidisciplinary teams; (iii) vertical integration; (iv) horizontal integration; (v) eHealth; (vi) integrated clinical pathways and dual referral systems; (vii) measurement and feedback; and (viii) certification and their accompanying strategies to achieve people-centred integrated care.15 The Luohu model implemented all the suggested core actions except certification (Table 1). First, under the Luohu model, patients are encouraged to sign a contract with a general practitioner based at a community health station and use him or her as the first point of contact with the Luohu hospital group. However, the gatekeeping system is not mandatory and allows an element of choice for patients. Second, in community health stations each primary health-care team consists of essential members: a general practitioner, a nurse, a public health physician and a health promotion practitioner. Teams may also include a pharmacist, psychologist or other specialist physician (e.g. geriatrician, paediatrician, internist) according to the needs of local residents. General practitioners lead in developing team Fig. 1. Organizational structure of the Luohu hospital group, Shenzhen city, China Manage Recall Supervise Recall Supervisory board Expert committee Council Luohu hospital group Workers’ congress President 6 resource-sharing centres 6 administrative centres 23 community health stations 5 hospitals 1 institute of medicine Zhongxun precision medical institute Medical testing centre Human resources centre General hospital Disinfection and supply centre Financial centre Maternity and child health-care hospital Health management centre Community health stations management centre Geriatric hospital Radiography centre Quality management centre Traditional Chinese medicine hospital Information centre Research and education centre Rehabilitation hospital Logistic and distribution centre General management centre Party committee Accountant
Policy practice Xin Wang et al People-centred care in urban China priorities,patient goals and care plans, records in their own system.With the review their personal performance and and approve test orders,medication and help of a Chinese internet company identify problems which are then used referrals. Luohu hospital group designed a new to drive continuous improvement. Third,the Luohu hospital group computer application called Healthy comprises 29 institutions at the com- Luohu,which all health-care providers Preliminary evaluation munity and district levels.In this vertical can access.Patients too can access their According to the annual self-evalu network,district-level hospitals focus on own medical records online. ations of the Luohu hospital group, providing complex care and emergency Sixth,there is a referral gateway 575012 residents (around 39%of the care for life-threatening situations. between community health stations population)had signed contracts with Community health stations provide and hospitals in the group.Patients primary health-care teams by July 2017 health promotion,preventive care,case can be referred from community From June 2015 to June 2017 increasing management and medical care for com- health stations to hospitals for expe- proportions of the population used ser- mon diseases dited care or can be referred back from vices in the Luohu hospital group rather Fourth,multidisciplinary primary hospitals for continuous rehabilitation than other hospitals outside the group health-care teams help to integrate dif- care and follow-up within primary after establishment of the integrated ferent types of care.Health promotion care.Patients referred via the gateway care programmes(Fig.2).Increasing staff was recruited from the former fam do not need to go through the hospital number of patients with diabetes,hy ily planning stations to provide health patient registration process and are pertension and severe mental illness are education for patients.Public health given priority for care in the hospital now under integrated case management physicians working at the Chinese Cen compared with those directly access- (Fig.3),which reflects greater collabo- ter for Disease Control and Prevention ing the hospital. ration between district-level hospitals provide services such as,responding to Seventh,the Luohu hospital group and community health stations.From and reporting infectious diseases and established a performance measure- 2015 to 2017 the administration ex- public health emergencies and monitor- ment system.The general manage- penses of the whole group reduced by ing domestic water supplies. ment centre is responsible for making 19%(from US$30.0 million to US$ Fifth,hospitals and community annual evaluations of performance 24.3 million),and the average salary health stations previously used two dif- using data collected by the informa- of staff in community health stations ferent electronic information systems tion centre (Fig.1).The results are increased by 10%(from US$26915 to and providers could only view patient communicated back to stakeholders to USS 29 607).Furthermore,a survey of Table 1.Core actions and strategies to achieve people-centred integrated care in Luohu district,Shenzhen city,China Core action Implementation Imple- Specfic description in the Luohu model Document reference area strategies mented? Primary care as Patient Yes Residents in Luohu district are encouraged to sign a Luohu government resolution first contact registration contract with a general practitioner voluntarily.The n0.24[2015: agreement defines a package of services,the service Implementation plan for delivery process,and the rights and obligations of both comprehensive reform of patient and provider. public hospitals in Luohu Contract period is one year with a specific general district practitioner.At the end of the period the patient can sign a contract with another general practitioner,which allows some element of patient choice. Risk stratification Under Previous electronic information systems could not NA preparation support risk stratification.Luohu hospital group is preparing to collect data for a risk stratification exercise based on disease burden,using a new computer application program. Gatekeeping Yes Patients are strongly encouraged to see their primary Luohu government resolution health-care provider before a visiting a hospital no.24[2015]: specialist.However,they are not formally required to do Implementation plan for 50. comprehensive reform of To promote patients'use of family medical practices as public hospitals in Luohu the first contact,district-level hospitals assign specialists district to work temporarily in community health stations. Ensuring e Home visits are provided for patients who sign a contract National Health and Family accessibility with a general practitioner,especially for the elderly Planning Commission of people. Luohu district resolution no 672015]: Implementation plan for home visits in Luohu district (continues...） Bull World Hea/th Organ 2018,96:843-852 doi:http://dx.doi.org/10.2471/BLT.18.214908 845
Bull World Health Organ 2018;96:843–852| doi: http://dx.doi.org/10.2471/BLT.18.214908 845 Policy & practice Xin Wang et al. People-centred care in urban China priorities, patient goals and care plans, and approve test orders, medication and referrals. Third, the Luohu hospital group comprises 29 institutions at the community and district levels. In this vertical network, district-level hospitals focus on providing complex care and emergency care for life-threatening situations. Community health stations provide health promotion, preventive care, case management and medical care for common diseases. Fourth, multidisciplinary primary health-care teams help to integrate different types of care. Health promotion staff was recruited from the former family planning stations to provide health education for patients. Public health physicians working at the Chinese Center for Disease Control and Prevention provide services such as, responding to and reporting infectious diseases and public health emergencies and monitoring domestic water supplies. Fifth, hospitals and community health stations previously used two different electronic information systems and providers could only view patient records in their own system. With the help of a Chinese internet company, Luohu hospital group designed a new computer application called Healthy Luohu, which all health-care providers can access. Patients too can access their own medical records online. Sixth, there is a referral gateway between community health stations and hospitals in the group. Patients can be referred from community health stations to hospitals for expedited care or can be referred back from hospitals for continuous rehabilitation care and follow-up within primary care. Patients referred via the gateway do not need to go through the hospital patient registration process and are given priority for care in the hospital compared with those directly accessing the hospital. Seventh, the Luohu hospital group established a performance measurement system. The general management centre is responsible for making annual evaluations of performance using data collected by the information centre (Fig. 1). The results are communicated back to stakeholders to review their personal performance and identify problems which are then used to drive continuous improvement. Preliminary evaluation According to the annual self-evaluations of the Luohu hospital group, 575 012 residents (around 39% of the population) had signed contracts with primary health-care teams by July 2017. From June 2015 to June 2017 increasing proportions of the population used services in the Luohu hospital group rather than other hospitals outside the group after establishment of the integrated care programmes (Fig. 2). Increasing number of patients with diabetes, hypertension and severe mental illness are now under integrated case management (Fig. 3), which reflects greater collaboration between district-level hospitals and community health stations. From 2015 to 2017 the administration expenses of the whole group reduced by 19% (from US$ 30.0 million to US$ 24.3 million), and the average salary of staff in community health stations increased by 10% (from US$ 26 915 to US$ 29 607). Furthermore, a survey of Table 1. Core actions and strategies to achieve people-centred integrated care in Luohu district, Shenzhen city, China Core action areaa Implementation strategiesa Implemented? Specific description in the Luohu model Document reference Primary care as first contact Patient registration Yes Residents in Luohu district are encouraged to sign a contract with a general practitioner voluntarily. The agreement defines a package of services, the service delivery process, and the rights and obligations of both patient and provider. Contract period is one year with a specific general practitioner. At the end of the period the patient can sign a contract with another general practitioner, which allows some element of patient choice. Luohu government resolution no. 24 [2015]: Implementation plan for comprehensive reform of public hospitals in Luohu district Risk stratification Under preparation Previous electronic information systems could not support risk stratification. Luohu hospital group is preparing to collect data for a risk stratification exercise based on disease burden, using a new computer application program. NA Gatekeeping Yes Patients are strongly encouraged to see their primary health-care provider before a visiting a hospital specialist. However, they are not formally required to do so. To promote patients’ use of family medical practices as the first contact, district-level hospitals assign specialists to work temporarily in community health stations. Luohu government resolution no. 24 [2015]: Implementation plan for comprehensive reform of public hospitals in Luohu district Ensuring accessibility Yes Home visits are provided for patients who sign a contract with a general practitioner, especially for the elderly people. National Health and Family Planning Commission of Luohu district resolution no. 67 [2015]: Implementation plan for home visits in Luohu district (continues. . .)
Policy &practice People-centred care in urban China Xin Wang et al. (...continued)） Core action Implementation Imple- Specific description in the Luohu model Document reference area' strategies mented? Multidisciplinary Team Yes In community health stations,each primary care team Luohu government resolution teams composition, consists of a general practitioner(leader),nurse,public no.5[2017乃： roles and health physician and health promotion practitioner and Lessons learnt from the leadership may also include specialist physicians (e.g.geriatrician, Luohu model to promote the paediatrician,internist),pharmacist,nutritionist or construction of district hospital psychologist. group in Shenzhen The roles of each member are clearly defined,with flexibility to adjust roles based on patients'needs and the context. Individual care Under The hospital group is preparing to use care plans for NA plans for patients preparation high-risk patients identifed by a risk stratification approach. Vertical Definition Yes The Luohu model defines the roles of each component Luohu government resolution integration of facility of the hospital group to ensure coordination. no.24[20151: roles within District-level hospitals are centres of excellence in Implementation plan for a vertically technology and staff expertise,focusing on providing comprehensive reform of integrated high complexity of care and valuable rescue care for public hospitals in Luohu network life-threatening situations.District hospitals also provide district technical assistance and training to community health Luohu hospital group stations. esolution no.3[2017刀 Community health stations focus on providing Charter of the Luohu hospital preventive care,rehabilitation,case management and group (revised version of 2017) medical care for common diseases Luohu government resolution no.5[2017小： Lessons learnt from the Luohu model to promote the construction of district hospital group in Shenzhen Provider- Yes In the hospital group,provider-to-provider relationships to-provider are strengthened through technical assistance and relationships capacity-building. District-level hospitals are responsible to provide clinical technical assistance through training,education and joint consultations to physicians in community health stations. Meanwhile,physicians in community health stations are encouraged to get three months of training in the hospitals Forming facility Yes The hospital group was established in the form of an networks independent corporation consisting of 23 community health stations,five district hospitals and an institute of precision medicine(which mainly provides diagnostic testing).A council of government officials and representatives from local communities was set up,to which the group are accountable to.Six administrative centres were re-organized using the resources of the respective centres in the former five district- level hospitals.Twelve centres provide resources and management for the whole group Horizontal Integrating of Yes The multidisciplinary primary health-care teams National Health and Family integration different types include former health promotion staff from family Planning Commission of Luohu of care planning stations,public health physicians from the district resolution no.4 [2016]: Chinese Center for Disease Control and Prevention and Implementation plan for specialists from hospitals.Teams work cooperatively appointing public health with other members to provide preventive care, physicians to work in screening,diagnosis,treatment,rehabilitation and case community health stations management for patients.Six resource-sharing centres (human resources,quality management,financial, research and education,community health station management and general management;Fig.1)allow for more efficient use of resources through reducing care overlap (continues...） 846 Bull World Hea/th Organ 2018:96:843-852 doi:http://dx.doi.org/10.2471/BLT.18.214908
846 Bull World Health Organ 2018;96:843–852| doi: http://dx.doi.org/10.2471/BLT.18.214908 Policy & practice People-centred care in urban China Xin Wang et al. Core action areaa Implementation strategiesa Implemented? Specific description in the Luohu model Document reference Multidisciplinary teams Team composition, roles and leadership Yes In community health stations, each primary care team consists of a general practitioner (leader), nurse, public health physician and health promotion practitioner and may also include specialist physicians (e.g. geriatrician, paediatrician, internist), pharmacist, nutritionist or psychologist. The roles of each member are clearly defined, with flexibility to adjust roles based on patients’ needs and the context. Luohu government resolution no. 5 [2017]: Lessons learnt from the Luohu model to promote the construction of district hospital group in Shenzhen Individual care plans for patients Under preparation The hospital group is preparing to use care plans for high-risk patients identified by a risk stratification approach. NA Vertical integration Definition of facility roles within a vertically integrated network Yes The Luohu model defines the roles of each component of the hospital group to ensure coordination. District-level hospitals are centres of excellence in technology and staff expertise, focusing on providing high complexity of care and valuable rescue care for life-threatening situations. District hospitals also provide technical assistance and training to community health stations. Community health stations focus on providing preventive care, rehabilitation, case management and medical care for common diseases Luohu government resolution no. 24 [2015]: Implementation plan for comprehensive reform of public hospitals in Luohu district Luohu hospital group resolution no. 3 [2017]: Charter of the Luohu hospital group (revised version of 2017) Luohu government resolution no.5 [2017]: Lessons learnt from the Luohu model to promote the construction of district hospital group in Shenzhen Providerto-provider relationships Yes In the hospital group, provider-to-provider relationships are strengthened through technical assistance and capacity-building. District-level hospitals are responsible to provide clinical technical assistance through training, education and joint consultations to physicians in community health stations. Meanwhile, physicians in community health stations are encouraged to get three months of training in the hospitals Forming facility networks Yes The hospital group was established in the form of an independent corporation consisting of 23 community health stations, five district hospitals and an institute of precision medicine (which mainly provides diagnostic testing). A council of government officials and representatives from local communities was set up, to which the group are accountable to. Six administrative centres were re-organized using the resources of the respective centres in the former five districtlevel hospitals. Twelve centres provide resources and management for the whole group Horizontal integration Integrating of different types of care Yes The multidisciplinary primary health-care teams include former health promotion staff from family planning stations, public health physicians from the Chinese Center for Disease Control and Prevention and specialists from hospitals. Teams work cooperatively with other members to provide preventive care, screening, diagnosis, treatment, rehabilitation and case management for patients. Six resource-sharing centres (human resources, quality management, financial, research and education, community health station management and general management; Fig. 1) allow for more efficient use of resources through reducing care overlap National Health and Family Planning Commission of Luohu district resolution no. 4 [2016]: Implementation plan for appointing public health physicians to work in community health stations (. . .continued) (continues. . .)
Policy practice Xin Wang et al People-centred care in urban China (...continued) Core action Implementation Imple- Specific description in the Luohu model Document reference area strategies mented? E-Health Integrated Yes The hospital group designed the Healthy Luohu Luohu government resolution electronic computer application.By logging into their personal n0.24[2015: medical records account,both providers and patients can access Implementation plan for systems electronic health records systems comprehensive reform of public hospitals in Luohu district Communication Yes The Healthy Luohu application allows patients to request and care an online appointment with a specific physician in all management institutions.Staff in community health stations can make functions an online referral for patients to hospitals. The application is also easy for patients to check physician information and update registration and payment forms Interoperability Under Providers in hospitals and community health stations NA of e-health preparation can view patient records in their own institution.Luohu across facilities hospital group is establishing regulations to allow the and services electronic systems to link across institutions securely and effectively Integrated Integrated Under Clinical pathways are being created to standardize the NA clinical clinical pathways preparation treatment and referral pathways between providers pathways and for care dual referral integration and decision support Dual referral Yes In the referral gateway model,patients referred from Luohu government resolution pathways within community health stations are expected to receive no.24[2015: integrated care expedited care in the district-level hospitals. Implementation plan for networks Down-referral,which allows referrals of patients from comprehensive reform of hospital to community health stations for rehabilitation public hospitals in Luohu care or follow-up,is incentivized by a new health district insurance payment system in the Luohu hospital group Measurement Standardized Yes The Luohu hospital group established a performance Luohu government resolution and feedback performance measurement system and makes annual self-evaluations. no.242015] measurement Indicators focus on measures of capacity-building of Implementation plan for indicators staff at community health stations(e.g.numbers of staff comprehensive reform of working in the community health stations,numbers of public hospitals in Luohu outpatients)and obtaining patients'experiences district Continuous Yes The results are communicated back to stakeholders at all feedback loops levels,early positive results and challenges are identifed to drive quality The hospital group is designing new strategies based on improvement measurement results of the last two years Certification Certification No NA NA criteria for local and national use Targets for No NA NA criteria and use to certify facilities NA:not applicable Core action areas and implementation strategies suggested by the policy report Deepening health reform in China. about 80%of residents in 10 districts Lessons learnt tals.Three reasons have been proposed found that satisfaction with health care for the fragmentation of services in in Luohu district ranked first among all Despite promoting care integration China:(i)fee-for-service payments; 10 districts in Shenzhen city.2 within the hospital group and first point (ii)fragmentation of financing;and The health ministry of China was of contact at community health stations, (iii)more generous health insurance satisfied with the results of the two- the Luohu model provided several les- for inpatient than outpatient services. year preliminary evaluation in Luohu sons to overcome challenges during Other researchers suggested that effec- Recognizing that it was a comprehen- implementation. tive care integration can be achieved sive model adopting and combining Improving collaboration without the need for the formal integra- strategies from other initiatives,the tion of organizations.However,the ministry began introducing the Luohu The first challenge was how to improve establishment of the Luohu hospital model to urban areas nationwide on 1 collaboration between community group created a strategy of integration September 2017. health stations and district-level hospi- across organizations and played a key Bull World Hea/th Organ 2018:96:843-852 doi:http://dx.doi.org/10.2471/BLT.18.214908 847
Bull World Health Organ 2018;96:843–852| doi: http://dx.doi.org/10.2471/BLT.18.214908 847 Policy & practice Xin Wang et al. People-centred care in urban China about 80% of residents in 10 districts found that satisfaction with health care in Luohu district ranked first among all 10 districts in Shenzhen city.22 The health ministry of China was satisfied with the results of the twoyear preliminary evaluation in Luohu. Recognizing that it was a comprehensive model adopting and combining strategies from other initiatives, the ministry began introducing the Luohu model to urban areas nationwide on 1 September 2017. Lessons learnt Despite promoting care integration within the hospital group and first point of contact at community health stations, the Luohu model provided several lessons to overcome challenges during implementation. Improving collaboration The first challenge was how to improve collaboration between community health stations and district-level hospitals. Three reasons have been proposed for the fragmentation of services in China: (i) fee-for-service payments; (ii) fragmentation of financing; and (iii) more generous health insurance for inpatient than outpatient services.23 Other researchers suggested that effective care integration can be achieved without the need for the formal integration of organizations.24–26 However, the establishment of the Luohu hospital group created a strategy of integration across organizations and played a key Core action areaa Implementation strategiesa Implemented? Specific description in the Luohu model Document reference E-Health Integrated electronic medical records systems Yes The hospital group designed the Healthy Luohu computer application. By logging into their personal account, both providers and patients can access electronic health records systems Luohu government resolution no. 24 [2015]: Implementation plan for comprehensive reform of public hospitals in Luohu district Communication and care management functions Yes The Healthy Luohu application allows patients to request an online appointment with a specific physician in all institutions. Staff in community health stations can make an online referral for patients to hospitals. The application is also easy for patients to check physician information and update registration and payment forms Interoperability of e-health across facilities and services Under preparation Providers in hospitals and community health stations can view patient records in their own institution. Luohu hospital group is establishing regulations to allow the electronic systems to link across institutions securely and effectively NA Integrated clinical pathways and dual referral Integrated clinical pathways for care integration and decision support Under preparation Clinical pathways are being created to standardize the treatment and referral pathways between providers NA Dual referral pathways within integrated care networks Yes In the referral gateway model, patients referred from community health stations are expected to receive expedited care in the district-level hospitals. Down-referral, which allows referrals of patients from hospital to community health stations for rehabilitation care or follow-up, is incentivized by a new health insurance payment system in the Luohu hospital group Luohu government resolution no. 24 [2015]: Implementation plan for comprehensive reform of public hospitals in Luohu district Measurement and feedback Standardized performance measurement indicators Yes The Luohu hospital group established a performance measurement system and makes annual self-evaluations. Indicators focus on measures of capacity-building of staff at community health stations (e.g. numbers of staff working in the community health stations, numbers of outpatients) and obtaining patients’ experiences Luohu government resolution no. 24 [2015]: Implementation plan for comprehensive reform of public hospitals in Luohu district Continuous feedback loops to drive quality improvement Yes The results are communicated back to stakeholders at all levels, early positive results and challenges are identified. The hospital group is designing new strategies based on measurement results of the last two years Certification Certification criteria for local and national use No NA NA Targets for criteria and use to certify facilities No NA NA NA: not applicable. a Core action areas and implementation strategies suggested by the policy report Deepening health reform in China. 15 (. . .continued)