Abstract
The definition of China’s integrated delivery system remains abstract since it was proposed in 2021, lacking detailed clarification on essential concepts such as specific contents and main providers of services for older adults with multimorbidity.
To develop an integrated care conceptual framework for older adults with multimorbidity within China’s integrated delivery system.
A scoping review, semi-structured interviews and a modified e-Delphi study were used to explore specific contents of integrated care for older adults with multimorbidity. A social network analysis was conducted to identify healthcare providers with the greatest potential to play a central role in the integrated care for older adults with multimorbidity. Finally, an integrated care conceptual framework was established based on specific contents and main providers.
The center of the framework represents the people-centered and need-oriented connotation of China’s integrated delivery system. The first circle reflects three significant characteristics of the integrated delivery system, namely care comprehensiveness, care coordination, and care continuity. The second circle includes main providers of integrated care, which are expected to play a central role in professional collaboration and information diffusion. The outermost circle consists of specific contents of integrated care, including clinical practice, human workforce, organisational collaboration, information technology, regulations and policies.
The framework derived from this study is expected to promote the understanding and implementation of integrated care for older adults with multimorbidity within the Chinese context. The service content of integrated care related to clinical practice also offers valuable references for other countries.
Key Points
This framework proposes a set of comprehensive and well-defined concepts for integrated care to address the complex healthcare needs of older adults with multimorbidity.
This framework also proposes several integrated care concepts that are tailored to the Chinese context to address the practical challenges faced by China’s new round of healthcare reform.
The development of this framework is expected to facilitate the understanding of integrated care for Chinese older adults with multimorbidity, inform future research, act as a reference guide for resource allocation, and ultimately contribute to healthy ageing.
Introduction
‘Multimorbidty’, referring to the coexistence of two or more chronic conditions in the same individual [1], has become a norm rather than an exception around the world, especially among older adults aged 60 years and over. The global prevalence of multimorbidity ranged from 30.5% to 75.5% [2, 3]. Individuals with multimorbidity are not only more likely to experience polypharmacy, complex self-management regimens and competitive health priorities [1, 4], but also are associated with a decline in health-related quality of life [5], frailty [6], disability [7] and even premature death [8]. Although multimorbidity is becoming more prevalent and important in clinical settings, global healthcare systems are primarily designed to address individual health conditions, with healthcare providers typically prioritising the most pressing problem that the patient is experiencing rather than providing person-centered and coordinated healthcare [9, 10]. As a result, individuals with multimorbidity often receive fragmented and even conflicting healthcare services [11]; [10]). Moreover, addressing only one health condition at a time is not an efficient approach for both patients and healthcare systems, especially when this population predominantly uses healthcare services [12, 13]. Therefore, the WHO declared in 2016 that multimorbidity poses a significant global challenge to patient safety and the sustainability of the healthcare system [1].
Given that individuals with multimorbidity have a complex and heterogeneous array of healthcare needs that can only be met through coordinated, continuous, and comprehensive support provided by a variety of healthcare providers across different disciplines, organisations and levels of care, ‘integrated care’ is increasingly recognised as a crucial component in their service provision [14, 15]. Since the concept of integrated care was proposed, various scholars and institutions have ascribed different definitions and connotations to it (eTable 1, Appendix 1). As defined by the WHO [14, 15], integrated care refers to healthcare services that are managed and delivered so that people receive a continuum of health promotion, disease prevention, diagnosis, treatment, management, rehabilitation and palliative care services, coordinated across different levels and sites of care within and beyond the health sector, and according to their needs throughout the life course.
China has made remarkable progress in improving equal access to healthcare, enhancing financial protection and strengthening its primary healthcare system during the initial phase of healthcare reform [10]. In 2021, China set a new objective to establish an ‘integrated delivery system’ and to prompt co-treatment and co-management of multiple chronic conditions for its healthcare reform. This system is characterised by the collaboration of various levels and types of healthcare organisations, the integration of diverse healthcare services and their management, and the provision of people-centered, lifelong and coherent services, according to the health needs of the population [16]. So far, China has launched several pilots for the integrated delivery system. However, a common characteristic of these models is their orientation towards the entire population, with a greater emphasis on unified governance structures within primary healthcare settings and hospitals. Taking the Luohu Hospital Group as an example [17], it considers integrated care for older adults and patients with chronic conditions as an essential strategy for the integrated delivery system. Nevertheless, this model lacks detailed clarification on specific contents and main providers of integrated care services for older adults or chronic patients, which hampers a systematic understanding of the integrated delivery system and, consequently, impedes the envisioning, design, provision, management and evaluation of integrated healthcare services for these groups.
As the population most in need of integrated care, there is a growing need for an integrated care conceptual framework for older adults with multimorbidity within China’s integrated delivery system, to transform the relatively abstract concept into a more pragmatic conceptual framework, thereby facilitating the understanding of integrated care for this population, informing future research, acting as a reference guide for the rational allocation of resources in practical settings, and ultimately contributing to healthy ageing. Therefore, the objective of this study was to develop an integrated care conceptual framework for older adults with multimorbidity within China’s integrated delivery system. In this present study, a conceptual framework is defined as a network of interconnected concepts that together offer a systematic and comprehensive understanding of a phenomenon or phenomena [18, 19].
Methods
The study was divided into three phases. Figure 1 shows the detailed objectives for each phase.
Three phases of the study.
Phase 1
Scoping review
A scoping review [20] along with an inductive thematic analysis [21] was conducted to identify existing models or programs and initially explore specific contents of integrated care for older adults with multimorbidity. Given the extensive and diverse literature on this subject, the method of a scoping review of reviews was employed to comprehensively synthesise the current state of knowledge as previously done in research [22]. As a result, 15 studies were included (eFigure 1, Appendix 1). Further details of the methodology for this scoping review have been detailed in published literature [11].
Semi-structured interviews
Semi-structured interviews [23] and inductive content analyses were employed to gain profound understandings of the viewpoints of healthcare providers and recipients, and to appropriately complement and adapt specific contents of integrated care for older adults with multimorbidity within the Chinese context. From September 2022 to June 2023, semi-structured interviews were conducted in Zhejiang Province, one of the national pilot provinces of integrated care in China. As shown in Figure 2, the healthcare system in Zhejiang has a typical three-tiered structure. A purposeful sampling combined with maximum variation sampling method was employed to recruit respondents from both healthcare providers and recipients within the three-tier healthcare system (including 11 healthcare organisations across four cities). The methods employed during the interview process and data transcription are detailed in Appendix 1. Interview data were ultimately collected from 14 patients and informal caregivers and 33 healthcare providers. The sociodemographic characteristics of the interviewees are summarised in eTable 3 (Appendix 1).
The typical three-tier healthcare system of Zhejiang Province, China.
Modified e-Delphi study
A modified e-Delphi study [24, 25] was used to reach expert consensus regarding specific contents of integrated care for older adults with multimorbidity between November and December 2023. Given that integrated care for older adults with multimorbidity involves clinical practice, scientific research and policymaking, experts were purposively selected to represent these three areas. Inclusion criteria of experts and the method for completing the questionnaire are shown in Appendix 1. Referring to previous literature [24, 26], 13 experts were invited to participate, and among them, 11 experts agreed to participate. Their sociodemographic information is summarised in eTable 4 (Appendix 1). The positivity of experts towards the questionnaire was indicated by the response rate. The authority of experts was measured by the coefficient of reliability (Cr). This indicator includes the basis for judgement (Ca) and the familiarity of indices (Cs), with the formula given by Cr = (Ca + Cs)/2. The degree of coordination among experts was tested by calculating the coefficient of variation (CV) and the Kendall’s W coefficient. Consensus was defined in this study as CV <0.25 and Kendall’s W > 0.4 with the P-value ≤0.05 [27].
Phase 2
A social network analysis [28] was applied in this phase to map out the interactions among healthcare providers through the sharing of older adults with multimorbidity, and to identify healthcare providers with the greatest potential to play a central role in the integrated care, from the perspective of professional collaboration and information diffusion. Patient sharing was defined as healthcare providers having a significant encounter with one or more common patients [29]. ‘Name generator’ and ‘name interpreter’—the most commonly used methods in social network analysis—were employed to collect data relevant to participants’ healthcare service utilisation [30]. Four healthcare organisations within the three-tier healthcare system in Zhejiang Province were selected. Older adults with multimorbidity seeking health examination, inpatient or outpatient services in these healthcare organisations were invited to participate in this study from July to December 2022. A total of 321 participants were included, with their detailed information presented in eTable 5 (Appendix 1). A one-mode network named as the ‘patient-sharing network’ was established using the data of healthcare service utilisation. The social network graph based on the Fruchterman-Reingold algorithm, centrality metrics and clique analysis were then applied to provide a comprehensive overview, as well as to identify densely interacted subgroups and central healthcare providers of the ‘patient-sharing network’. Further details of the methodology for the social network analysis have been published elsewhere [31].
Phase 3
The findings from the scoping review, semi-structured interviews, modified e-Delphi study and social network analysis were integrated to develop a framework called the integrated care conceptual framework for older adults with multimorbidity.
Ethical considerations
Ethics approval was obtained from the Ethics Committee of Zhejiang University School of Medicine Sir Run Run Shaw Hospital [ID: 2022–0130]. All participants were informed of the research purpose and provided informed consent to participate.
Results
Phase 1
A consensus among experts was reached on 23 elements, forming the specific contents of integrated care for older adults with multimorbidity (eTable 6, Appendix 1). The response rate of the two rounds of expert consultation was 84.6% and 100%, respectively, indicating a high level of expert positivity. The Cr of the two rounds both exceeded 0.7, with values of 0.91 and 0.85, suggesting that the expert authority was reliable. The CV of the two rounds was both lower than 0.25. The Kendall’s W coefficient of the two rounds was 0.261 and 0.439, respectively (P < 0.05), with the value of the second round higher than that of the first round, implying a good degree of coordination among experts.
Phase 2
Degree centrality and weighted degree centrality signify activity and popularity, closeness centrality measures independence and efficiency, while betweenness centrality indicates power. The amount of overlap among the healthcare providers identified in each of the cliques enables the identification of core members in the network [28].
In the ‘patient-sharing network’ (eTable 7 and eFigure 2, Appendix 1), general practitioners, cardiologists, pharmacists, gastroenterologists, neurologists, respiratory specialists, endocrinologists and emergency physicians working across the three-tier healthcare system were identified as healthcare providers with the greatest potential to play a central role in the integrated care for older adults with multimorbidity, considering that from the perspective of professional collaboration and information diffusion, the more connected or central a healthcare provider is, the more popular, efficient, and powerful it is in the network [28]. Additionally, primary healthcare providers were extensively involved in patient-sharing relationships with others due to their highest level of centrality metrics and the largest number of overlapping cliques. Thus, they are expected to play a particularly important role in professional collaboration and information diffusion.
Phase 3
Integrated care conceptual framework for older adults with multimorbidity was established after integrating the results of Phase 1 (specific contents) and Phase 2 (main providers). As shown in Figure 3, the center of the framework represents the people-centered and need-oriented connotation of the integrated delivery system. The first circle reflects three significant characteristics of the integrated delivery system: (i) care comprehensiveness: the integration of diverse healthcare services and their management, (ii) care coordination: the collaboration of various levels and types of healthcare organisations and (iii) care continuity: the provision of lifelong and coherent healthcare services. The second circle includes main healthcare providers involved in the integrated care for older adults with multimorbidity. They are expected to play a central role in professional collaboration and information diffusion, facilitated by the shared patients among them. The outermost circle is composed of specific contents of integrated care for older adults with multimorbidity, including clinical practice, human workforce, organisational collaboration, information technology, regulations and policies.
The integrated care conceptual framework for older adults with multimorbidity within China’s integrated delivery system.
Discussion
By recruiting and engaging healthcare providers, recipients, and experts in China, and investigating the status of healthcare service provision and utilisation, existing barriers, and potential facilitators, the integrated care conceptual framework for older adults with multimorbidity within China’s integrated delivery system was ultimately established. It proposes a set of comprehensive and well-defined concepts for integrated care to address the complex healthcare needs of older adults with multimorbidity, as well as several integrated care concepts that are tailored to the Chinese context to address the practical challenges faced by China’s new round of healthcare reform. Therefore, the development of this framework is expected to facilitate the understanding of integrated care for Chinese older adults with multimorbidity, inform future research, act as a reference guide for resource allocation, and ultimately contribute to healthy ageing.
In 2021, China explicitly set the primary goal of its new round of healthcare reform as establishing a primary healthcare-based integrated delivery system against the acceleration of population ageing and the nationwide epidemic of non-communicable diseases. To achieve this goal, the government has implemented a series of actions, including enhancing the quality of primary healthcare providers, building formal alliances between primary healthcare settings and hospitals to coordinate incentives and governance among healthcare organisations, exploring a unified digital platform to facilitate information sharing within the healthcare system, and educating the public on the value of prevention and health maintenance. These actions ensure the feasibility of the framework derived from this study within the Chinese context.
However, the application of this framework in China still faces challenges. First, a large number of older adults with multimorbidity have already overloaded China’s healthcare system and providers [10], indicating the necessity to take measures to ensure a sustainable and fit-for-purpose healthcare workforce, particularly family physicians, general practitioners, and geriatricians, to alleviate the workload on the healthcare system and to achieve a balance between supply and demand. Measures that can be taken include promoting education and training that reflects the roles and technical changes of co-treatment and co-management of multiple chronic conditions, as well as trends in interdisciplinary work, enhancing career development opportunities, promoting the health and well-being of staff, incorporating more types of healthcare providers such as pharmacists, nutritionists, therapists, and psychologists with broad and direct participation and active service delivery, and improving the recruitment, retention, and morale of interdisciplinary healthcare providers [32].
Second, the Chinese healthcare system was characterised by excessive marketisation in the 1980s, which led to the isolation and competition for patients among primary healthcare settings and secondary and tertiary hospitals [33]. Although the implementation of healthcare reform has strengthened collaborations between healthcare organisations, the general population still have the freedom to choose any healthcare organisation within the three-tiered healthcare system, without being required to first visit or refer from their family physicians [31]; [10]). Therefore, to achieve in-depth collaboration among healthcare organisations and optimise the pathways for patients to access healthcare services, it is urgent to eliminate societal discrimination against primary healthcare settings and enhance public trust in them. Additionally, the Chinese government should introduce more policies and regulations to guide patients to seek healthcare services in an orderly manner.
Third, although China has made remarkable progress in enhancing financial protection during the initial phase of healthcare reform, the current mechanisms of healthcare payment and insurance are not fully adapted to multimorbidity. For instance, the current payment mechanism is characterised by fee-for-service (i.e. surgeries, medications, and medical tests) instead of fee-for-value (i.e. health education and comprehensive geriatric assessments). To further reduce healthcare expenses and the economic burden on older adults with multimorbidity, while enabling healthcare payment and reimbursement mechanisms to adapt to multimorbidity, the Chinese government should increase financial investments in the healthcare and social care for older adults as a prerequisite.
As one of the typical pilots of the Chinese integrated delivery system, the Luohu Hospital Group was established in 2015. The group adopted a series of professional, organisational, system, functional, and normative strategies for integrated care and had been proven to translate into better service provision, higher patient satisfaction, and changes of disease incidence [17]. Although the proposal of the Luohu model is also in the context of population ageing and the high prevalence of chronic conditions, the model serves the general population in practice, including children and adults, as well as individuals at health risk, acute patients and chronic patients. Therefore, compared to the Luohu model, the integrated care conceptual framework derived from this study is characterised by providing more detailed healthcare concepts and connotations specifically tailored for older adults with multimorbidity, particularly for service contents such as comprehensive geriatric assessment, innovative payment and reimbursement mechanisms adapted for multiple chronic conditions, and service providers such as geriatric interdisciplinary teams as well as the final decision-maker.
Implications
The development of an integrated care conceptual framework for older adults with multimorbidity within the Chinese integrated delivery system has a few implications for facilitating the systematic understanding of the phenomenon and informing healthcare and social care policy, practice, and scientific research.
(1) Strengthen the capabilities of family physicians, primary healthcare providers, and geriatricians for co-treatment and co-management of multimorbidity; accordingly, high-quality healthcare resources should be appropriately directed towards these professionals.
(2) Enhance trust in primary healthcare settings and providers across society and optimise the order of first visit and two-way referral between primary healthcare settings and secondary/tertiary hospitals.
(3) Establish a digital platform enabling healthcare providers within and across organisations to work as interdisciplinary teams and refine the workflows, evaluations, and incentive mechanisms of interdisciplinary teams.
(4) Coordinate not only healthcare providers and organisations, but also information, payment, and insurance systems and mechanisms for the pandemic of multimorbidity among older adults.
(5) Involve not only interdisciplinary healthcare providers, but also patients themselves, informal caregivers and communities in social care.
Limitations
Firstly, a scoping review of reviews was conducted to comprehensively explore specific contents of integrated care from a large body of literature, which resulted in some missing information that was only provided in original articles. Secondly, participants of semi-structured interviews and social network analysis as well as experts included in two rounds of the modified e-Delphi consultations were exclusively recruited in Zhejiang Province, which may weaken their geographical representation and interpretation. However, as Zhejiang Province not only has a typical three-tier healthcare system but also serves as a national pilot province for China’s integrated delivery system, the results of this study are still expected to be feasible in other regions and provide insights. Additionally, the specific contents of integrated care that are not related to a particular healthcare system (i.e. innovative reimbursement mechanism and policy integration) but are directly related to older adults with multimorbidity (i.e. comprehensive geriatric assessment, case manager, and final decision-maker) can also provide valuable references for other countries. Thirdly, although the number of experts is considered feasible [24], only 11 experts were included. Fourthly, although people are generally better at recalling typical or routine events [28], the utilisation of healthcare services in social network analysis was self-reported using the methods of ‘name generator’ and ‘name interpreter’, which might introduce recall bias and reduce data accuracy.
Conclusion
An integrated care conceptual framework for older adults with multimorbidity was developed in this study. This framework consists of 23 elements regarding specific contents of integrated care and healthcare providers with the greatest potential to play a central role in the integrated care from the perspective of professional collaboration and information diffusion. These findings are expected to promote the understanding and implementation of integrated care for older adults with multimorbidity within the Chinese context. The service content of integrated care related to clinical practice also offers valuable references for other countries.
Declaration of Conflicts of Interest:
None.
Declaration of Sources of Funding:
This work was supported by the National Social Science Foundation (20BGL275).
References
Braun V, Clarke V. Using thematic analysis in psychology.
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