| I Background and Significance1.1 With the increasing number of the aged, the society is showing an aging trend.Aging is an inevitable production of social development, and a symbol of human civilization as well. With socio-economic and modern medical development after the World War II, Human beings’life expectancy has been gradually increasing. What is more, faster speed of life and work, change of fertility consciousness, and sharp decline of birth rate end in an obvious transition of the global population structure. The world’s population is facing an aging trend.China has the largest number of both total population and aging population. From 1999, the speed of aging has accelerated. According to data from the Sixth National Census, the elders who are aged over 60 years account for l3.26% of the whole population, and the elders aged over 65 years account for 8.87%. As the most developed city in China, Shanghai has 2,329,840 people aged over 65 years, accounting for 10.12% of the total. Shanghai has already entered an aging society and will experience more pressure brought by aging.Aging is a must trend of social development in China and in the world. Facing all the related problems and challenges, how to tackle with the social pressure and make the elders live happily should be considered by policy researchers and makers.1.2 The need for long-term care (medical and life care) in the aging society is urgent.Aging trend in the society is accelerating, which cause both physical and psychological health of old people to decline. And that makes the need of aged people for medical、caring and psychological help more and more urgent.First of all, disability is the main reason of the aged people demanding medical and life care. With then-age growing, risks remaining in the environment will increase as their body functions decline, diseases increase, and self-care ability diminishes. At the same time, scale of families becomes smaller as the result of birth control policy. Large numbers of "four-two-one", "four-two-two", "eight-four-one-two"’or even empty nest families appear, which has a great impact on the traditional home-care model and disease care function.In addition, mortality、disability rate and morbidity of the aged are much higher than that of the total population in China. According to statistics in 1994 of Ministry of Health, city residents older than 65 suffer a morbidity of 60.2% which is 1.54 times higher than that of the total population; while in rural areas, the rate of the 65-years-above is 22.6% which is 2.1 times higher than that of the total rural population. Furthermore, most of the diseases of the aged are chronic and have a long course of treatment and a high disability rate, which greatly affected their lives.Therefore, to provide the aged with both medical and life care to make sure that they spend their remaining years in comfort is quite necessary. Luckily, long-term care is exactly a comprehensive system combining health care and daily-life care, which meet the actual need of the aged. In short, long-term care should be the most important part in the current aged care in china.1.3 To fulfill the blank of domestic and international research in this filed1.3.1 International research progressThe concept of long-term care was put forward in 1960s or 1970s, when developed countries started to take social care into consideration on the basis of completing health care system. Both quantity and quality of care services for the aged developed rapidly. From then on, researches have mainly focused on long-term care services and long-term care security service, and the elderly population becomes the focus of concern as the main group who need these services.In the beginning, researches on long-term care mostly focused on the tendency of the development of the need for long-term care, especially the relationship between the cost of healthcare and aging. With the development of the practice in long-term care, the theme of it has expanded from simply economic problems to the demand of long-term care such as service supply and types of services. Recently, the focus has turned to improving life quality and personalized services.International researches on long-term care security and insurances started in 1970s, when many countries faced the increasing long-term care costs which increased the government’s financial burden. Governments began to build long-term care security and insurance system, so many concrete and comprehensive requirements and standards have formed in the fields of financing mode, service objects, nursing methods, hierarchy classification, payment method, premium apportion, etc. Thus long-term care service was enhanced in the world. As the implementation of the long-term care security system, a series of new issues emerged such as the function of long-term care insurance, adverse selection of the insurance market and moral risks. Many famous foreign experts and scholars are studied in these issues.In a word, after years of practice, western countries have established a complete care service and security system for the aged which have obtained good effects in operation. There are many precious experiences for us to reference. What is more, they have acquired many multi-perspective academic achievements in long-term care study, which provides important references and analytical framework.1.3.2 Domestic research statusThrough systematical review of "Chinese journal full-text database" (1993-2010 years), we found 107 articles related to elderly care. And we found that research on the aged care in China is far behind developed countries. Because Chinese elderly care service system has not been set up, domestic long-term care research is still in its beginning stage. Generally speaking, researches on the aged care sendee have already covered systemic structure, process, service effects, influence of the external environment and so on. But when we come to a single study, all of those researches are scattered and superficial. In addition, many literatures are either just argumentative review, mainly qualitatively discussion, published in less quality magazines, lack of comprehensive systemic survey and first-hand data, still at the stage of problems discovering, experience absorption and theory exploration and lack of deep researches about the current situations of our aged care system which includes resources situation, service provision, aged care related policies, regulations, standards and methods. Researches on long-term care and long-term care insurance are still in exploration stage and are mostly introduction of foreign institutions and imagination of our system. This may because our country has not established a long-term care service and security system. Real long-term care insurance products have not appeared. The construction of service system is especially important than the establishment of security system. And how to focus on the field of long-term care service and try to establish long-term care insurance system on the basis of service system should be orientation of researches.For the aged care services in China, what are the most important problems? How to research key strategies aiming at solving those problems? These are the most urgent questions we need to answer and the areas this paper intends to break through.II Materials and MethodsThis research used the scientific program for policy making, macroscopic model of health system, qualitative and quantitative multiple demonstration, multiple dimension evaluation method as guidance. The scientific program for policy making was applied to systematically collect problems existing in aged care service and to develop strategies to solve outstanding issues and necessary support systems via induction and deduction, literature analysis, and real number argument. Macroscopic model of health system was mainly used to find the relationship between those problems and the mechanism of the outstanding problems. Qualitative and quantitative multiple demonstration was used to prevent theory-practice-separation. Aiming at main thoughts and views, synthetically use "literature qualitative and quantitative demonstration, real data validation, the supplier and the buyer’s intention demonstration" to multiply prove and inspection. Multiple dimension evaluation combines different agencies, different regions, aged care service providers, organizers and consumers, situation and forecast of human, material and financial resources, retrospective literature study, cross-sectional and prospective forecast, and management and research procedure of current situation of aged care, problems, causes and policies.The applied methods of this research included literature induction and cross-sectional survey. The self-care ability of service objects and of the aged living in communities is calculated via Barthel Index.This research adopted randomly stratified cluster sampling to determine the six sample counties. Objects of this survey were nursing homes in Shanghai, including 17 first named institutions,54 second and third named institutions, and 36 community health centers. Service providers included 82 leaders of health bureau in Shanghai from 18 districts (counties), leaders of aged care institutions and workers and registered nurses of sampling nursing homes total in 986,2303 hospitalized patients, and 2073 old residents from the sample areas. Content of the survey included disposition of the organization, intention investigation of the organizers and providers, and buyers’the health situation, demand and usage of service.Ⅲ Results3.1 The construction status of the care system for the aged in Shanghai3.1.1 The status of the system for the aged careThe institutions related to long-term aged services in Shanghai, including the institutions of care and of medical treatment for the aged, undertake the relative services of care and medical treatment. The result implied that there were totally 404 relative institutions concerning the aged care and medical treatment in Shanghai in 2010, including 71 aged nursing homes (among which there was 17 instruction firstly titled and 54 second and third titled),237 community health centre,4 aged hospitals, and 76 secondary comprehensive hospitals,16 comprehensive privately-owned hospitals,40752 family beds as well as 1161 relative aged service institutions.3.1.2 The status of Human ResourcesIn 2010, the average level of employed staff in each aged service institution in Shanghai was 51.05 medical professionals,16.33 nursing workers,1.65 volunteers. And each institution averagely had 26.48 doctors,19.63 nurses and 0.25 assistant nurses. The rate between the amount of the aged nursing beds and the staff was 1: 0.67, still not matching the standard of 1:0.8 by the Requirement of Ministry of Health.With regard to the change of time, the amount of employed medical staff raised from the average of 49.23 in 2006 to 55.89 in 2010, with the yearly growth rate of 3.22%. The health care staff in enrollment increased from 25.39 in 2006 to 28.98 in 2010, the increasing rate was only 2.29%, slower than the former of 3.22%. Within the five years there remained a difference between staff in employment and quota of enrollment, as well as the increasing rate, which could not meet the practical requirements.3.1.3 Funds input and management of the institutionsAmong the relevant institutions of aged care in Shanghai in 2010, the proportion of the institutions with a little profit and with a profit rate higher than 10 percent were 50.7% and 14.2%. But there was still about 25% institution had a 10% deficit. The financial input rate of various types of aged care institutions lied about 10%, which is obviously inadequate. The hospitalized medical treatment income was 3,884.38 thousand Yuan, while the hospitalized drug income was 2778.51 Yuan. The former was higher than the latter, may because the income of the institutions mainly came from the long-term hospitalized services. But the income of institutions taking hospitalized services as the main service model was not high. Therefore, the condition is not optimistic with regard to the low input and 25% deficit.3.1.4 Current status of equipments and facilitiesThe average housing space of each aged care institution was about 2364.41 square meters in 2010; the housing space for business was at the average of 1914.13 square meters; the total amount of beds for aged care was 17770 and of wards was 5476. Among the present 32 kinds of basic instruments relative to aged care, covered 74.8% of the Basic Standard of Nursing Homes (2011 Version), the usage rate of total instruments (not only aged care ones) covered 70.1% of those in the standard. Although the rate seemed not to be so low, it still didn’t reached 100%. According to the listed 12 basic instruments in Basic Standard of Aged Nursing Homes in Shanghai (1999 Version), the usage rate was 81.2%, also failing to get a 100% coverage.3.1.5 Business status of aged care servicesAs for the 14 relevant technical departments mentioned in Basic Standard of Nursing Homes (2011 version), the gradual independent practice rate was 75.8%; among them, the highest was the clinic medicine wards and nursing site, with the rate of 96.9%; the second was the General Practice (GP, doctor) offices with the percentage of 95.9%. The technical departments with lowest practice rate were the hospice rooms and the chatting rooms. Analyzing the cause of failing to set the departments independently, the main reason was lack of housing space for business, which accounted for the rate of 32.3%; the second reason was sharing resources with other offices, accounted for 20.1%, and the other 17.5% with condition limitations.Among the services applied now, the practice rate of health care reached 88.2%, the rate of daily life caring reached 95.5%.3.1.6 Situation analysis of hospitalized patients and discharged patients of aged nursingAmong 2303 inpatients in elderly nursing hospitals, the medical insurance coverage was as high as 98.4%, of which the Medical Insurance of Urban Employees counted for the most (51.1%). Their main financial source was from retirement allowance and average of it for each person was 2151.59 Yuan per month. Among these aged people, more than half were feeling lonely and nervous for their situation. The prevalence rate of chronic diseases of this group had reached 98.7% and 78.9% people had more than two kinds of chronic diseases. It was advisable that related departments should pay more attention to improving physical and mental health of the aged population.Among 30668 discharged patients in 74 aged care facilities, people older than 80 years accounted for more than 60.0%, industrial workers with nonagricultural registration accounted for 45.0%, and people covered by Medical Insurance of Urban Employees accounted for 63.1%. The average length of hospital stay was 110 days and each bed cost 127.62 Yuan per day for medical treatment.3.1.7 Situation analysis of aged people living in communityThe medical insurance coverage rate of the 2012 aged people who participated in this survey was as high as 98.6%.84.6% of them lived depending mainly on retirement allowance. What’s more, the prevalence rate of chronic diseases of this group had reached 77.29% and the top ten chronic diseases were:hypertension, heart disease, diabetes, cataract, cranial vascular disease, rheumatoid arthritis, bronchitis, enterogastritis, prostatitis, intervertebral disc disease. It was much the same as the top ten chronic diseases of the entire aged population in China’s Health Service Survey in 2008.Among all the surveyed community aged people,1.8% of them had difficulties in taking care of themselves. We can also calculate out the total ratio (8.98%) of disabled aged people from the hospitalized people (53.8%) and community people’s disabled rate.The cognitive rate of aged care among the community aged people was rather high (65.3%). People who would like to choose aged care when they could not take care of themselves accounted for 51.2%. As much as 71.3% of them regarded the "Disease Diagnosis and Treatment" as the most urgent service in aged care institutions, and 34.4% of them would like to choose nursing homes when they became disabled while 36.6% of them would choose nursing hospital.The main reason that aged people chose nursing hospital was that they had no ability to take care of themselves in their daily lives. There were also many aged people who wanted to go to aged nursing hospital but failed.60.0% of them considered the fee was too high to afford, while 26.6% failed because of the shortage of beds.3.2 The key issue and its formation mechanism of nursing care for the aged in Shanghai269 problems, which discovered by reviewing, analyzing and summarizing the relative articles from Chinese Academic Journal Full-text database from 1993 to 2010 have been grouped into 25 types of problems that are concerning the service system, security, and other management for long-term care or aged care based on the Macro-Model of Health System.According to the mentioned proportion of problems in the articles, the problem of "the nursing care, especially medical nursing care is in short supply" become the first serious problem which called the key issue by researchers. On other hand,82.0% of 986 participants including Aged care organizers and providers also much agreed with these 25 problems which are truly existing in Shanghai’s aged care service system and the key problem "the nursing care, especially medical nursing care is in short supply" is also agreed by as much as 95.3% of them.Based on the theory of "the Macro-Model of Health System" which representing the health care system from "structure", "process" to "outcome" and their interactions, the formation mechanism of the key issue existing in nursing care system in Shanghai is developed.Firstly, from the outside of the system, demographic needs along with social-economic development, as China has been entering into an aging society, the aging population become bigger and bigger and it with no doubt brings out more aged care in need as a result. One of the most important reasons of how the key issue takes shape is people’s misunderstanding of aged care. In acquirers’ eyes, they regard the aged care as life care so when they run into the situation that they cannot take care of themselves they would like to take part in aged care organization while in the organizer and suppliers eyes, the misunderstanding of aged care’s function by the acquirers will lead to the shortage of nursing care relatively.For the aged are lack of understanding about medical and social security, it will confuse them to choose a suitable way to receive the caring when they can’t take care of themselves, home care, medical care or nursing care? And the lack of security system will also result in that the suppliers’induction affecting the acquirer’s choices, including medical treatment, nursing service etc.Secondly, the internal management of aged care has always been taking the clinical nursing treatment for the aged patients as the main service of the nursing management system. But as the category expansion of aged care, such kind of management is not adapted. The lack of long-term planning for aged care market and shortsighted advantage oriented behavior is not fit for the public properties of aged care. Here to list some outstanding performances:function orientation of aged care is not clear, lack of evaluation standard of service, agencies lack of outpatient and inpatient standards, standards of quality management are too much wide; professional nursing education about aged care and professional scientific research projects are in short; a clear and uniform standard in aged care charges; incentive mechanism for aged care staff are not able to firing the enthusiasm of them; the lack of care insurance especially for the aged.When comes to resources which is influenced by environmental factors, the government has paid limited attention on aged care; government’s finance to the Aged care facilities is insufficient in both absolute and relative quantity; Aged care beds are insufficient and not well-distributed; professionals working in aged care organizations are lack of technology and their traditional concepts need to be changed.In the process, first of all, because of government’s finance shortfall, there be lack of nursing staff and necessary equipment both in quantity and quality.Secondly, aged care facilities are lack of long-term planning and function orientation and evaluation standard. Thirdly, the lack of related law and supervision system result in the lack of sense of responsibility of the nursing service. Fourthly, the lack of medical and social security, especially for there be no insurance for the aged which would bring about the profit behavior.Finally, in the outcome system, for the function orientation forbid, lack of evaluation for patient out-hospital standard. Some over use aged medical care resources by power intention and lack of long-term aged insurance. So together with service process and the allocation of resources and the shortcoming of the structure, the aged care services, especially health care services are in short supply become the common problem in health care system.3.3 Policies and strategies on how to improve the nursing care for the agedBased on the key issue and its formation mechanism, policies and strategies on how to improve the nursing care for the aged have been put forward by an intent investigating to leaders of the district, county health bureaus, workers and registered nurses, the group who are most concerned to this key issue.Firstly, the government should attach more importance on the nursing care for the aged and guide the whole society, especially the relative organizations and institutions to care about this field.Whether the key issue existing inside the system depends on whether the problems are in the external environment, which include the government’s attention, financial and cooperative aid and so on.Secondly, clearly define the function orientation and the hospital admitting standards. Establish the admission and discharge standards, evaluate the state of the patient in health system, can help us to insure the nursing care institution are serving the objects.Thirdly, provide more resource to the aged care system by adding nurse beds, cultivating multi-level aged care talents and inventing aged equipment and facilities. This is the root solution for the problemsFourthly, the rules and regulations provided by related departments of government become much useful to stimulate the development of aged care system.Fifthly, it’s of great importance to develop the community-based care, home-based care and organization-based care at the same time with enhancing home bed building to ease pressure of the aged care system.3.4 Researches on the necessary technologies to be used in the construction of aged care service system in Shanghai3.4.1 Conception of the functions of aged care system in ShanghaiLong-term care is different from health care, which involves all kinds of nursing services for persons suffering disability. There is no generally accepted conception of long-term care yet in the world. Long-term care should consist of the following contents according to our comprehensive analysis of the researches at home and abroad:(1) the need for care is long-term; (2) the purpose is to raise the quality of life and health of the service objects; (3) the service objects, who are completely or partly disabled, are mostly elderly and chronic patients and do not have the ability to care for themselves; (4) service can be provided by families, communities, medical institutions, living aid institutions (houses for the elderly) and nursing homes; (5) Services such as medical services, social services, home services, transport services or other supportive services are provided by professional nursing staff like registered nurses or nursing assistants and non-professional persons like family members or untrained housekeepers. Because the aged are the main objects of long-term care services, the concept of "elderly long-term care" is easy to draw. "Elderly long-term care" refers to the process of providing the aged who has physical or mental dysfunction with emotional comfort and long-term comprehensive care services.Based on literature review and investigations of institutions and service providers, this research constructed the structure of long-term care system in Shanghai, i.e. long-term care being provided by both the health sector and civil administration sector. Institutions that provide services are classified as medical institutions, communities, families and social welfare institutions (such as nursing homes, etc.), according to the proportion differs from the amount of medical care and life care in their services. Medical institutions, mostly secondary and tertiary hospitals and some community health centers, mainly undertake the acute phase of care; rehabilitation hospitals and nursing centers undertake the sub-acute phase of medical care; nursing homes, community health centers, community nursing institutions and home beds undertake the stable phase of medical care; houses for the elderly, elderly service centers, nursing homes and social welfare institutions mainly undertake life care services. Medical care and life care are difficult to be completely separated. All the agencies above have provided both health and life care, and the composition of medical care steps down backward while the life care proportion rises gradually. Consequently, objects of the aged health care institutions must meet two conditions: (1) being unable to take care of themselves is the prerequisite; (2) fitting for some standards or conditions of health or medical care. Both of them are necessary.3.4.2 Resources measurement research aimed at achieving long-term care3.4.2.1 The estimating thoughts, procedure and the calculated result of hospice beds based on long-term careIn order to meet the elderly care service needs and requirements of these aged care institutions in Shanghai, the study developed the estimating thoughts and steps of hospice beds, which based on the date from surveys on institutions, community population and hospital patients and the definition of objects in elderly health care institutions.First, Based on the situation of the community people’s ability of daily life and required hospitalization without hospitalization, It can estimate the newly elderly persons’long-term care service needs, and then eliminate the inpatients needs caused by entirely life care needs. So that, we can obtain the new geriatric medical care demands. As a result, the newly increasing beds can be easy to get.Second, considering of the excessive use of phenomenon existing in present medical care service objects, we can calculate the effectively needs of long-term care beds in hospitalized patients when eliminating the beds occupied by non-medical nursing subjects who are full of self-care abilities.Third, considering that the aged care institutions also have some medical care, we can calculate number of beds of the elderly medical care needs according to the existing pension institution occupied beds and in need of medical care service ratio.Forth, the total beds, which come from the effectively needs in medical care and pension institutions, plus additional community aged care beds so that we can get the ideal bed demand.Fifth, for pension and health care institutions have already converted needs, could the needs in community translate into a demand? The study calculate an ideal needs of beds through the survey data, which have removed the unchanged demands because it cannot afford the cost, Of course, the existing bed utilization rate in the study also fully taken into account.Sixth, with the data of existing and predicted future population, we use ratio method to predict the tendency of medical care beds development and the gap size in Shanghai under the imagination that aged population will not be influenced by policy.Under the guidance of the step above, medical care institutions have only 24769 beds, with more 12599 beds needed to meet the whole need of 37638 beds. To meet the demand of the population, there is still a gap for 12599 and 6081 pieces while in the year of 2015 the gap may respectively be 15842 and 8009 copies. When considering the fact that by the end of 2010 the use ratio of aged care beds is 89.6% in Shanghai, the gap should be changed to 10023 and 3595 pieces in 2011 and 12819 and 4986 pieces in 2015.3.4.2.2 Needs/Demands estimation on human resources allocation based on long-term nursing care.With regard to service efficiency of existing sickbed based on the concept of long-term care, to meet the requirement in aged care constitution in 2011, it has the demand of totally 29894 people in nursing staff, it should reach the amount of 19594 by requirement based on the amount 10300 present available. According to the rate of 1:2 between the amount of Registered Nurses and nursing staff, there is the need of 9965 registered nurses and 19930 nursing staff, so that the lack was 4295 and 15300 respectively. For the same way, it could be analysed by the ideal model of the demand in sickbed of aged care in 2011, there is the lack of 14380 people in total amount of nurse, the amount of 2257 registered nurses as well as 11823 nursing staff nowadays.3.4.2.3 Needs/demands estimation of allocated equipments and facilities of the long-term medical care for the agedOur research conducted allocation estimation of current status and forecasted development. As for the current status, we could get the number of institutions failing to allocate certain equipment by multiplying non-allocation rate of the equipment with the total number of relevant institutions. And then multiply that number with the average unit price of each equipment to get the total amount of funds that we need to input to facilitate that equipment. As for the forecasted development, we calculate the beds need to be added from both the view of long-term care need and of demand. We assume scale of current institutions remain unchanged, and measure the number of institutions need to be increased, i.e. beds need to be added, based on the number of existing beds of each institutions.According to the device requirements of Basic Standard of Nursing Homes (2011 version), a total of 161.8 million Yuan needs to be invested for the current amount of hospital beds. Considering the increase of institutions as a consequence of bed increase, and the service efficiency of existing beds is only 89.6%, from the view of population need and of demand, we can calculate that there is 317.4 million Yuan in need and 221.7 million Yuan in demand. We could certainly introduce care services from home beds, aged care institutions and medical institutions to release the financial pressure of increasing hospital beds for the aged, then the investment of device and facilities would be reduced to 161.8 million Yuan.According to the listed 12 basic facilities in Basic Standard of Aged Nursing Homes in Shanghai (1999 Version), the general allocation rate is 81.2%, and the independent practice rate of most technical departments is over 80%. The main reason for not allocating some departments is lack of business housing space, with the portion of 32.3%. It is clear that functional orientation and operation space are the more fundamental reasons compared to financial input. So the key to the problem is adequate operation space. The government only needs to pay close attention to the instruction and practice guarantee of macro-policies instead of to invest large amounts of funds.IV Innovation and Weakness of the Study4.1 Result Innovation4.1.1 By using qualitative and quantitative methods including literature induction, analytic method, cross-sectional survey and intention survey, the prominent problems and interaction mechanism of our country’s aged nursing service system were firstly systematically and comprehensively stated. What is more, strategies for the key point to solve the prominent problems had been made. Besides, the calculation about the need and demand in aged care provided a scientific reference for the aged care work in Shanghai and provided scientific basis for other similar researches.4.1.2 By systematic survey of three kinds of aged care institutions and community health centers, and by questionnaire of leaders, staff a... |
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