| BackgroundWith the change of disease spectrum and aging population,the epidemiological burden and economic burden of chronic disease is increasingly rapidly.At the same time,there is a high requirement for pattern,type and quality of health care,as the complexity of chronic disease prevention and treatment,and inhabitants' health consciousness.However,health care system in China is fragmented,lack of referrals of coordination among institutions.The health care delivery pattern with low efficiency,which is led by hospitals,centered by treatment,operated by single institution,is difficult to meet the inhabitants' health needs.Therefore,health care integration becomes an important issue for China and many other counties all over the world.In 1980s,health consortium emerged in China,which was a form of health care integration.But,the later development was slowly.Since the implementation of"Equalization of basic public health services project" in 2009,the discontinuitious health care delivery pattern has been changed,which promoted health care integration in several provinces.Especially after 2015,policies related to strengthen health care system acceleranted two-way referral of diabetes and hypertension.However,policy makers are facing the same challenge:how to promote health care integration by taking effective measurements in Chinese health care systems?And how to evaluate the impact of health care integration?Literature review shows that most health care integration researches are theoretical researches,only a few are practical researches.Among practical researches,most of them are qualitative description of the design and process of health care integration pilots,a few of them are related to effect evaluation.Most of effect evaluation researches are conducted by interviews,which show positive effect.But,little is known about effect of different strategies at different health care integration steps.Moreover,there is no research related to contextual factors influencing the implementation of health care integration.Overall,researches and practices in China are not theory-based or methodology-supported.Developed countries,such as America and UK,has started health care integration since 1970s,in order to solve problems of the health care systems.Recently,health care integration cases in developed counties pay attention to regularly monitor and self-evaluation of effect.In regard to evaluation method,most of them are combined by qualitative and quantitative method.Quality and continuity of health care,health expenditure changes are evaluated,with experiences of different cases being introduced.And the evaluation researches release health care integration's different effects on health care systems and provide evidence for optimizing health care integration strategies.However,some researchers pointed out that the existing evaluation method and indices could not show characteristics of integrated health care,such as continuity and coordination.Therefore,methodological breakthroughs are needed for integrated health care evaluation.What's more,health care integration depends a lot on background of each health care system.Influencing factors,evaluation methods or results may not be applied to China directly.ObjectivesThe main aim of this study is to analyze the contextual factors influencing health care integration and to evaluate the effect of health care integration in some Chinese health care systems,in order to provide evidence-based policies for other integration cases.There are four specific aims:(1)to describe contextual factors and strategies of health care integration cases,and analyze the factors which may influence the implementation of health care integration;(2)to build a model for evaluating health care integration;(3)to evaluate the effect of some health care integration cases;(4)to provide policies for promoting health care integration in different health care systems.MethodsThis is a cross-sectional case study.Data were collected by a project "Analyzing the roles and functions of healthcare institutions:To provide policy basis for the construction of integrated health service system",which is supported by The United Nations International Children's Fund.The study were conduced by three steps,literature review(Jul,2013-Jun,2014),expert consultation(May-Jun,2014)and field survey(Jul-Sep,2014).We explored the influencing factors of health care integration and the potential effect of health care integration,came up with hypothesis,and built conceptual framework by literature review of social network theory and related researches.Best practice for hypertension and diabetes were made through consulting twenty experts,which provide evidence for effect evaluation.Taking integration,pluralism and function division of health care systems into consideration,Chengbei district,Huangzhong county and Hualong county in Qinghai province,Ma anshan city,Feixi county and Feidong county in Anhui province,Jianggan district,Sanmen county and Changshan county in Zhejiang province were adopted in the study.Institutions of different types and at different levels were selected for in each health care system.In total,134 institutions,134 key informants,97 doctors for diabetes,88 doctors for schizophrenia,and 248 in-and outpatients were surveyed.They provided data on health resources and service inventory.health care integration's structure,process and outcome evaluation,background factors of health care system,strategies of health care integration,coordination of diabetes and schizophrenia care delivery,and so on.Data on background factors of health care system,health resources and service inventory,amount and efficiency of health care,patients' satisfaction were described by ratio,constitution ration and relative ratio.Social network analysis was employed to assess the process of health care integration,and gap analysis was adopted to assess the coordination outcome of health care integration.Results(1)Contextual factors influencing health care integration.Government leads health care integration,health administrative departments fully allocate health resources and promote health care integration,and institutions trust and cooperate with each other.(2)Strategies for health care integration.Aims for integration of four integrated cases are not specific enough,including promoting hierarchical medical system and optimizing collaboration mechanisms.Organizational integration and functional integration are main integration strategies,with information sharing,two-way referral and joint training.But,clinical integration,professional integration or normative integration are excluded.(3)Evaluation of health care integration structure.Health resources allocation and service inventory in integrated cases are not all better than unintegrated cases.In regard to health resource allocation,urban health care systems have more resources than rural health care systems in Anhui province and Zhejiang province,but it is the opposite in Qinghai province.Comparing health resource allocation between counties in the same province,Hualong and Feixi have more resources than Huangzhong and Feidong,both Changshan and Sanmen lacks sufficient resources.The most rational service inventory in three provinces are integrated rural health care system,then are urban health care system,lastly are unintegrated rural health care systems.(4)Evaluation of health care intgration process.Cooperations among institutions in integrated health care systems are more than unintegrated health care systems.In Qinghai province,referral network in Huangzhong is more normative than in Chengbei and Hualong,district-level institutions in Chengbei are not core members of the network,and there are more out-of-county institutions in Hualong than in Chengbei and Huangzhong.In Anhui province,relationships among institutions in Ma anshan is the most closely among three health care systems,there are close relationships among county hospitals and township health centers in Feixi,and there is a lack of close relationships among institutions in Feidong.In Zhejiang province,county hospitals in Sanmen has the least close relationships with other institutions than Changshan and Jianggan,information sharing network in Changshan has the least close connections among three health care systems.(5)Evaluation of health care integration outcome.Evaluation results of integrated cases are not all better than unintegrated cases.Participants' satisfaction and care coordiantion of schizophrenia service delivery in integrated cases are better than in unintegrated cases.However,service efficiency of the whole health care systems and coordination of diabetes sercice delivery in integrated cases are not better than unintegrated cases.Conclusion and policy implicationConclusion(1)Contextual factors,which influence health care integration,include government's leading role,health administration's ability to allocate health resources and make plan for development,trust and cooperation among institutions.(2)The health care system structure for care integration is unreasonable,especially service inventory of the whole health care system.The allocation of health resources does not match with service inventory.The aims and strategies of health care integration neglect the improvement of health care system structure.(3)The process of health care integration goes well,and it promotes the cooperation among different institutions.There are two reasons:firstly,some strategies are related to promote cooperation among institutions;secondly,the establishement of cooperation meet the demand of various institutions.(4)The outcome of health care integration has not been clear yet.At system level,service efficiency in some integrated cases is not higher than in unintegrated cases,which may result from unreasonable health care system structure and lag effect.At institutional level,the care of schizophrenia(with large gap index)in integrated cases is more coordinated than in unintegrated cases.At individual level,patients,satisfaction in integrated cases is higher than in unintegrated cases.Policy implicationBased on conclusion of this study and background of Chinese health care systems,we would like to give the following suggestions from two perspectives:creating an enabling environment;designing,implementing and evaluating health care integration.Creating an enabling environment(1)The government is supposed to lead health care integration in most cases.The integration process should be governed by a committee,which is consist of government,society groups,institutions,doctors and patients.Moreover,the government needs to create an enabling environment for implementing health care integration by formulating policies,such as workfore planning and payment reform.In some cases,other qualified non-government organization could be encouraged to lead health care integration.(2)Conducting health care integration within a county,and strengthening the independence of health care system.County is the basic administrative unit,which has a relative complete health care system structure and the ability to allocate health resources.In addition to maintain the independence of health care system,we should make full use of health resoures in the whole system and promote cooperation and coordination among institutions,in order to advance service inventory and provide high-quality continious health care.(3)Improving health care quality of primary health care institutions,and promoting care coordination among institutions.As some primary health care institutions are lack of ability to provide service needed by patients referred from higher-level institutions,increasing training and developing multi-institution guideline for different diseases are suggested to improve health care quality of primary health care institutions.(4)Empowering and engaging people.Firstly,to strengthen residents' health literacy and self-care ability by health promotion and health education and to enhance their understanding of three-tier health care system.Secondly,to increase residents'recognition of hierarchical medical system by media publicity.Thirdly,to guide two-way referral by medical insurance payment.Designing,implementing and evaluating health care integration(1)Combining vertical and horizontal health care integration,and constructing a differentiated service delivery network.Before conducting health care integration,we should match the level,type,service target,technical level and scale of institutions,in order to reduce inter-institution conflicts of interests and make a shared vision of integration aims.(2)Improving service inventory based on patients' needs,and allocating health resources reasonably.To define the service type and process of each institution and to optimize the service inventory of the whole health care system.To change the method of resource allocation,which is based on service utilization.Matching service inventory with health resource allocation,in order to promote integration of health resources and efficiency of resource usage.(3)Determing appropriate integration objectives,and adopting comprehensive integration strategies.First of all,to determine appropriate and specific objectives based on national policy and local health care system background.Then,to adopt targeted strategies for integration objectives and to adjust strategies regularly.It is necessary to adopt clinical and professional integration strategies,in order to promote health care integration.(4)Evaluating the effectiveness of health care integration regularly,and promoting the practice.There is no "one model fits all".Therefore,it is essential to get feedback by regular evaluation,and to adjust objectives and strategies for integration based on the feedback. |
PDF Full Text Request