Long-Term Care Residents’ Perceptions of Integrated Care From Physio-Psycho-Social Perspectives: A Qualitative Inquiry

Abstract

In response to the aging population, an integrated care policy has been put forward and implemented in China. The key aspect of this policy is the reform of services within long-term care facilities, representing a significant shift and innovation. This study aims to explore the perceptions and experiences of integrated care among older residents living in long-term care facilities. A descriptive qualitative design was applied in our study. Utilizing a purposive sampling method, 18 older adults from 5 long-term care institutions in Shanghai, China were selected. Data were collected through semi-structured in-depth interviews from October 2022 to April 2023, continuing until data saturation was reached. Directed content analysis was applied to analyze the interview data, guided by the Fundamentals of Care (FoC) Framework. Five themes and 11 subthemes were identified, including (1) Policy level: positive attitude and negative feelings. (2) Physiological level: satisfied basic daily life, primary medical services accessibility and chronic care management enhancement needed. (3) Psychological level: need for psychological support and need for self-perception recognition. (4) Relationship level: enhancement of humanistic care and need for a family atmosphere. (5) Social level: interpersonal communication constrained by the times and inadequate social engagement. Strengthening the awareness and participation of older people in the integrated care policy, and fully meeting the diverse needs including advanced medical care, chronic disease management, personalized life care, psychological support, humanistic care and social engagement will contribute to the improvement of the policy, so as to better adapt the demographic shift.

• What do we already know about this topic?

• China has implemented a nationwide policy—integrated care policy, which united health, social and long-term care services to adapt to the rapidly aging society and the huge burden of the aging population. As the main place of policy implementation, long-term care facilities take important responsibility of promoting the quality of life and health outcomes of the older adults in their later years.

• How does your research contribute to the field?

• This study focused on the perceptions and perspectives on integrated care among older adults. Based on the FoC Framework, we found that the long-term care residents highly acknowledged the original intent of the policy design and the improvement of daily life care, primary medical services and overall service quality, but they were not satisfied with advanced medical services, specialized chronic disease management, psychological support, humanistic care and social participation.

• What are your research’s implications toward theory, practice, or policy?

• This study explored first-hand experiences and perceptions of old people, offering valuable insights for enhancing and advancing the integrated care policy. Policy advocacy, financial mechanisms, healthcare enhancements, family and social support systems all deserve further consideration.

Introduction

“Integration” forms the foundational pillar within the continuum of long-term care for older adults. The concept of “integrated care” was first delineated and elucidated by Kodner and Spreeuwenberg as “the ‘glue’ that united healthcare institutions and providers, or the health, social services, and related systems in which they operate, enabling them to achieve common goals and optimal results.” ¹

China remains the most populous country and has the largest aging population. ² According to the latest data from National Bureau of Statistics, by the end of 2021, the number of people aged over 65 was 200.56 million, which accounted for 14.2% of the total population. ³ It is estimated that by 2040, the number of older adults will reach 400 million, accounting for nearly 30% of the total population, and by 2050, China will enter a new stage of rapid aging, facing challenges to ensure that the health and social systems are ready to adapt the most of the demographic shift.^4,5

In response to these imminent challenges, China introduced “integrated care” into its long-term care system in 2013, also known as the “yi-yang-jie-he” (in Chinese) policies. ⁶ These strategic policies aimed to integrate medical services and long-term care resources across hierarchical levels to sufficiently cater to the geriatric population’s health and social requisites. ⁷ Within this integrated care framework, the Long-term Care Insurance (LTCI) system emerges as a pivotal component. Its primary objective is to provide daily life care and nursing services for older adults at home and financial compensation for long-term care residents.

Long-term care facilities are the main settings to implement the policies of integrated care, especially with the shifting demographics and evolving ideologies within China, that more and more older people are willing to stay in these institutions.^6,7 By the end of 2020, China has established 5857 integrated long-term care facilities, equipped to deliver both medical services and long-term care.^8,9

Current researches in the field of integrated care mainly focused on the following topics: (1) policy optimization of governance, financing mechanism, workforce and service delivery from the perspectives of policymakers or researchers. ¹⁰ (2) the choice preference and influencing factors of older adults on integrated care model conducted by quantitative design. ¹¹ (3) subjective well-being or quality of life of older adults living in community model. ¹² (4) utilization of integrated care services and LTCI. ¹³

Given the novelty of the long-term care institutional model, there have been few studies on this aspect. ¹¹ However, we identified this as a pivotal aspect of the integrated care policy, meriting in-depth exploration. Meanwhile, we found that there were few studies on the perceptions and experiences of policies that care about the old people, resulting in a significant lack of evaluation and feedback from the primary beneficiaries, which greatly affected the effectiveness of the policies. ¹⁴ A profound understanding of older people’s perceptions can help identify the issues they care about most, and provide effective, high-quality services to support them.

The Fundamentals of Care (FoC) Framework is chosen as the theoretical lens for this study. This is because an increasing number of studies have found that care services in long-care institutions are provided in a healthcare provider-centered environment, rather than in a person-centered environment. ¹⁵ The FoC Framework is precisely designed to address such issues. It was developed by Alison Kitson’s team, which emphasized the value of person-centeredness. Based on people’s most basic needs, it proposed a three-tiered concentric circle structure including the trusting relationship between care recipient and care provider; integration of physical, psychosocial, and relational needs; and a supportive context, which helped to provide a comprehensive understanding of the physical, psychosocial, social, relationship and policy aspects of care that are central to the experiences of long-term care residents. ¹⁶

This study aims to explore the perceptions and lived experiences toward integrated care among long-term care residents under the guidance of the FoC Framework in order to help the long-term care system to optimize policies and formulate necessary service practice guidelines.

Methods

Study Design

A descriptive qualitative design was applied in our study, which was entirely based on the perceptions of older adults, and aimed to directly explore their perceptions about integrated care and experience of integrated care service. This approach allows for a descriptive summary and interpretation of findings, keeping the analysis at a level that is easily understood, and provides a clear and concise description. ¹⁷

Settings and Participants

Study settings

This study took Shanghai as the representative research city. As one of the pioneering cities in China to reform integrated care policies, Shanghai also has a notably high aging population. According to the recent report, by the end of 2022, the population aged 60 and over exceeded 5.53 million, accounting for 36.8% of Shanghai’s total population. There were 366 long-term care facilities in Shanghai providing both medical services and social care. ¹⁸

Through purposive sampling, 2 out of 16 districts in Shanghai—Xuhui District and Minhang District were selected as the survey areas. Five representative long-term care institutions in the above districts were chosen as the final study sites.

Study participants

Purposive sampling was used in our study, allowing researchers to select participants who were more likely to provide rich and relevant data. ¹⁹ Older adults were selected based on a variety of factors, including institution type, age, gender, education level, length of stay and self-care ability. The inclusion criteria for participants included: (1) aged over 65; (2) having at least one chronic disease; (3) duration of residence over 6 months; (4) informed consent and voluntary participation in this study; (5) clear consciousness and the ability to understand and answer questions accurately.

We first established contact with the person in charge of the research sites, and signed a cooperation and privacy protection agreement. Then, our researchers entered facilities for internship and interviewee recruitment, and conducted interviews after establishing trust relationship with participants to ensure the reliability, depth and richness of research data.

The research followed the principles of information sufficiency and saturation. When the data was saturated and there was no new information or theme presented, the sample selection was stopped. ²⁰ Finally, when we interviewed the 18th participant, no new code occurred, and data saturation was achieved.

Data Collection

Interview guide

In our scoping review on integrated care and long-term care for older people, an initial interview outline was developed using the FoC Framework. ²¹ Following a review by a geriatric expert and 2 pre-interviews with residents, the interview outline was refined. The final detailed interview guide is attached in the Supplemental Materials (Table 1). Notably, we tried to prepare more questions and include probes and prompts during the interview to get more responses from each participant, which was crucial for achieving data saturation. ²⁰

Table 1.

Interview Guide.

Interview Guide
CONTEXT OF CARE
Do you know about the integrated care policy? Probe: Have you heard about integrated care? How do you know that (from facility staff or family or social media)? How much do you know? Can you give some details or contents of the policy?
How do you feel about the implementation of the integrated care policy? Probe: Do you think the content of policy is rich or not?
Do you have the long-term care insurance?
How much do you know about the long-term care insurance? Probe: How much do you need to pay? The role of the long-term care insurance? What kinds of services are covered by long-term care insurance?
Are you satisfied with the long-term care insurance? Probe: Why? Or Why not? [If yes] What parts of the long-term care insurance are you satisfied with? [If no] What is the most unsatisfactory part? How do you think it could be improved?
Have you received any other benefits or subsidies?
INTEGRATION OF CARE
What integrated care services did you receive?
a) From physiological aspects? Probe: personal cleansing and dressing, medication management, comfort, medical services, etc.
b) From psychosocial aspects? Probe: family support, peer support, emotional wellbeing, etc.
c) From relational aspects? Probe: respect, dignity, privacy, empathy, etc.
How are these services provided? Probe: Who provides these services respectively? Which service provides the most?
Which of these services do you think are more important for you?
What do you think of the quality of these services? Probe: Whether these services meet your needs? Are you satisfied with them?
Which services do you think need to be further provided or improved?
RELATIONSHIP
Do you know who has provided integrated care services for you?
Do you think you have a good relationship with them? [If yes] How do you feel about that? [If no] Why? What do you think is the cause of your not pretty well relationship?
Can healthcare providers keep up to date with changes in your health?
Others
What are your expectations and suggestions for the integrated care policy and long-term care system for older adults?
Is there anything else you would like to share?

Data collection procedure

Although we encountered a large-scale epidemic of COVID-19 in the study area at the early stage of data collection, we still made every effort to overcome these challenges and ensured that all interviews were conducted face to face for in-depth exploration and comprehensive information gathering.

Informed consent was obtained from the participants before the interviews. The purpose, methodology and content of the research were thoroughly explained to ensure that residents could make an informed decision to participate voluntarily, and they were assured that their personal privacy would be kept confidential, and the interview contents were only used for academic research. They had the rights to withdraw from the study at any time and would not be affected.

Semi-structured in-depth personal interviews were conducted from October 2022 to April 2023 with each lasting approximately 30 to 90 min, which enabled researchers to collect detailed and rich data about participants’ experiences and perceptions, providing valuable insights into study topics. ¹⁹ Interviews were conducted in a quiet, secure and private setting, usually in participants’ living rooms or the research site’s conference room. Each interview was conducted in the presence of a participant and a researcher who had established a trusting relationship with the participant and possessed extensive experience in qualitative research. All the researchers are female. With the participants’ consent, the interviews were audio-recorded, and the researchers took concurrent notes. During the interviews, an introduction of this study was first made by researchers, following by an in-depth interview, adjusting the order of questions in the interview guide according to the actual situation, verifying unclear statements through restatement and clarification to avoid ambiguity, and finally inviting the participants to provide personal information. None of the participants withdrew interviews and quitted the study. The interviews were conducted until data saturation. Participants received a 50 RMB mug after interviews as compensation for their time and support.

Data Analysis

Directed content analysis was applied to analyze the interview data, which allowed researchers to interpret meaning from the data and analyze them with a theory or relevant research findings as guidance for initial codes. ²²

The entire process included several procedures. First, all interviews were transcribed, organized and integrated within 24 h by 3 researchers. Next, 2 researchers familiarized themselves with the data by reading repeatedly and immersed into the data. Then, the data was identified and coded independently. Finally, the coding was revised, combined and generalized into subthemes and themes based on FoC Framework under the discussion of the whole team. The entire analysis process was supported by Nvivo 12.0.

Rigor and Trustworthiness

The rigor of this study includes ensuring credibility, dependability, confirmability, and authenticity of the findings. All interviewers practiced in research sites for 3 months before interviews to establish trust relationship between participants. All researchers specifically underwent the necessary training and possessed substantial relevant experience of qualitative studies. Throughout the data collection and analysis procedure, researchers maintained an unbiased and objective approach. The thematic analysis process was a collaborative effort within the research team to reach consensus. The Consolidated Criteria for Reporting Qualitative Research (COREQ) checklist was used to guide the reporting of this study (see in Supplemental Materials). ²³

Results

A total of 18 long-term care residents were interviewed, including 4 men and 14 women, aged 69 to 97, with chronic diseases from 1 to 6. Further demographic characteristics of participants are presented in Table 2.

Table 2.

Participants Characteristics (N = 18).

Participants	Gender	Age	Education	Marital status	Child	Duration of residence (years)	Number of chronic diseases	Personal income (RMB)	Self-care ability a
P1	Female	69	College	Married	Yes	1	1	5000-6000	2
P2	Female	78	Elementary school	Married	Yes	3	3	7000-8000	3
P3	Male	77	College	Married	Yes	1	2	10 000-12 000	0
P4	Female	75	College	Married	Yes	1	1	6000-7000	2
P5	Female	72	Elementary school	Widowed	Yes	0.5	2	2000-3000	1
P6	Female	70	High school	Widowed	Yes	1	1	4000-5000	3
P7	Female	70	High school	Widowed	Yes	3	2	3000-4000	2
P8	Female	76	College	Widowed	Yes	1	1	3000-4000	2
P9	Female	78	College	Widowed	Yes	1	1	4000-5000	2
P10	Female	78	High school	Widowed	Yes	5	3	5000-6000	1
P11	Male	72	Middle school	Widowed	Yes	1	1	4000-5000	2
P12	Female	80	Elementary school	Widowed	Yes	1	2	2000-3000	1
P13	Male	70	Middle school	Married	Yes	2	2	3000-4000	2
P14	Male	96	Elementary school	Married	Yes	7	3	3000-4000	0
P15	Female	85	College	Widowed	Yes	3	2	5000-6000	1
P16	Female	97	Junior college	Widowed	Yes	0.5	3	5000-6000	0
P17	Female	83	Junior college	Widowed	Yes	3	6	4000-5000	2
P18	Female	89	Elementary school	Widowed	Yes	4	5	2000-3000	2

^aSelf-care ability: 0 = complete disability, 1 = moderate-to-severe disability, 2 = mild disability, 3 = complete self-care.

Based on the FoC Framework, we identified 5 themes and 11 subthemes of perceptions and feelings on integrated care among long-term care residents (Table 3).

Table 3.

Summary of identified themes and subthemes.

Themes	Subthemes
Policy level	Positive attitude
	Negative feelings
Physiological level	Satisfied basic daily life
	Primary medical services accessibility
	Chronic care management enhancement needed
Psychological level	Need for strengthened psychological support
	Need for self-perception recognition
Relationship level	Enhancement of humanistic care
	Need for a family atmosphere
Social level	Interpersonal communication constrained by the times
	Inadequate social engagement

Policy Level

Positive Attitude

Most long-term care residents were unfamiliar with the concept of integrated care, with some encountering the term for the first time during the study. Only few participants have been exposed to the policy through television, newspapers and other media channels. But overall, they had a positive attitude toward the integrated care policy.

“I understand that ‘yi’ means medical services and ‘yang’ is aged care or long-term care, and if these two can be combined and integrated is very well, but I do not know much about the policies.” (P5)

“I think if this policy can be well-implemented in long-term care facilities, more older adults will be willing to stay.” (P3)

They were notably more aware of and concerned with the LTCI system, particularly the provision of subsidies. These subsidies have alleviated their economic burden to a significant extent.

“The LTCI aims to cover our care expenditures, which we only pay 15% by ourselves, and the government will deduct the remaining cost for us.” (P1)

Negative Feelings

Several participants indicated that they did not perceive the practical implementation of the policy.

“They (government staff) advertised the policy as an integration of medical services and elderly care, but it did not implement well, and I could not feel any changes in care.” (P1)

Meanwhile, there were also many participants reflected the assessment problem of LTCI system. “Exploiting loopholes” and “divorce from reality” were often mentioned by the older adults.

“When LTCI assessors arrived, I could have walked down the stairs but they made me use a wheelchair and pretend to be disability and dementia.” (P2)

“LTCI assessors only asked me two very simple questions, and after I answered, they just hurried to leave. I saw that they just wrote hypertension and diabetes in my evaluation results. However, my actual condition is much more serious than that. In fact, I have malignant hypertension and a sudden cerebral hemorrhage history, which are very dangerous.” (P13)

In addition, even though the LTCI system has alleviated some of the economic burden on older adults, many aged people, especially those with cancer, continued to face considerable economic strain.

“I used to work in an enterprise, with a monthly pension of about 5000 RMB, which only covers my stay in the nursing home. The costs of medical treatment are rarely enough (sobbing).” (P1)

Physiological Level

Satisfied Basic Daily Life

Participants generally agreed that their fundamental physical needs were well met by the long-term care facility staff.

“Physical needs, including delivering meals, cleaning, toileting, and drinking water are all satisfied.” (P3)

At the same time, they said that they had an enriching day at the institution.

“My one day in nursing home is very busy, including reading newspapers, listening to music, and helping to take care of my wife (who has dementia).” (P13)

Overall, they were generally satisfied with their daily life in long-term care facilities. However, individual preferences, including dietary choices and cleanliness expectations, varied among residents.

“I do not think the food here is to my taste. It can’t be personalized.” (P2)

“The clothes here are washed together, which I think is not appropriate. Some old people clothes are very dirty and sloppy.” (P4)

Primary Medical Services Accessibility

Chronic health conditions were the predominant health-related subject discussed among the residents on a daily basis.

“What we usually talk about most is our chronic diseases, and we will comfort each other. We care more about our health and need more about health care.” (P2)

Some participants expressed that their primary motivation for residing in a long-term care facility is emergency preparedness and response — to ensure timely and life-saving assistance. They put great importance on the ability of long-term care facilities to provide medical services at any time.

“I take my health very seriously. The reason why I decided to move into this nursing home was just in case something happened, and it could save my life immediately!” (P14)

Almost all the participants acknowledged the quality of medical service provided in long-term care facilities, which could address common diseases. Also, the allocation and management of routine medications within the facilities were not reported as issues.

“The common medicine for hypertension, hyperlipidemia, heart disease and constipation are all available. If I get constipated, it can be solved just inside the nursing home.” (P4)

However, if they have further medical needs, it is difficult to meet them, which is complained by the participants.

“Every time I went to the hospital to see a doctor, I had to use antibiotics by intravenous drip for at least one week. If I took the medicine back to the nursing home for more comfortable environment and convenience, there was no one can help me with the medication. It really bothers me a lot!” (P12)

“The medicine (hypnotics) I take every day is not available in our facility, so my children are required to fill the prescriptions in other hospitals and send it for me.” (P15)

Consequently, several participants expected to further integrate long-term care facilities into the medical treatment alliance and establish a convenient referral system between long-term care facilities and hospitals.

“I hope long-term care facilities can establish cooperative relationship with hospitals and give us a convenient referral.” (P4)

In addition, they complaint that remote medical platforms did not have any practical use and also concerned about the security and privacy.

“I know about the remote medical platform, while I have never seen anyone use it.” (P1)

“Our institution has developed this platform, but we still have to go to hospitals by ourselves.” (P4)

Chronic Care Management Enhancement Needed

Chronic disease management is considered as the main function of long-term care facilities, but a few participants reported a shortfall in the provision of specialized nursing and rehabilitation training in institutions.

“I had some problems with my teeth once. I felt a lot of pain those days, so I was very anxious to solve them. While, there was no dentist in the nursing home or professional clinic nearby, which took me a long way to find a clinic to deal with them. . .. . .Also I had diabetes-related foot disease, and I asked if they (doctor and nurses in her nursing home) had any medicine and could help me with it. They said ‘no’ without any hesitation.” (she threw up her hands) (P2)

“There is no professional rehabilitation training and doctor in the nursing home, and I really need it because of my poor leg.” (P15)

Some participants also mentioned that although there were blood pressure and blood glucose management in the institution, it is formalized.

“If you feel uncomfortable, and want to take your blood pressure, sometimes you have to find them (doctor and nurses in her nursing home) yourself, they will not come to measure and care about you all the time.” (P11)

“Once I had a sudden attack (malignant hypertension). Fortunately, my eyes could still see and I did not pass out, so I went to get help and ran a layer before I found one nursing assistant! (with anger)” (P13)

Psychological Level

Need for Strengthened Psychological Support

“Desire for freedom and someone to talk to” were the most frequently mentioned psychological needs of the participants.

“I don’t have any other needs, and I just want to be able to move around freely without restrictions. . .. . .I’m very glad to talk to a young girl just like you. I hope this could last longer.” (P4)

Due to the distance, long-term care residents often faced limited family visits, which increased their sense of inner loneliness, and even led to negative psychology and extreme behaviors.

“I saw less of my family since I’ve been living here, especially during the COVID-19 pandemic, which restricted my personal freedom, so I kind of want to die (wipes tears).” (P3)

Need for Self-Perception Recognition

(1) Life Perception

Most participants conveyed a conscious awareness of their lifespan, with some adopting a positive attitude toward embracing their remaining years.

“At this age anyway, I want to live happily every day.” (P1)

While, some participants, unable to contribute to society due to illness or other reasons, exhibited negative attitudes.

“The desire to enjoy life is not much. I think people are alive to contribute to society, so I feel that there is no value in living like this.” (P3)

“I am suffering from this disease (malignant tumor) and feel miserable and unhappy in my old age.” (P9)

• (2) Competence Perception

The majority expressed a determination to carry out self-care to the extent of their capabilities, upholding a strong belief in the principle of “self-reliance support.”

“I do what I can on my own, with a little help from nursing assistants. I think it’s better to do things ourselves. ‘Hands are brains’——if you depend on others too much, you are more likely to develop dementia.” (P17)

There were also some participants who wanted to improve their ability to keep up with new times.

“Nowadays, young people rely on smartphones which is very convenient. We actually want to learn it, too. In fact, it’s useless and unsustainable for young people to help us operate once and once again. Next time, we still do not know how to use. That’s why it is best to learn on our own.” (P18)

Relationship Level

Enhancement of Humanistic Care

Although the overall quality of care was approved by the participants, there was a unanimous call for an enhanced humanistic approach to care, highlighting the importance of respect, empathy, and patience—qualities considered more crucial than technical skills alone.

“A couple of nurses and nursing assistants showed disrespectful and impolite to me. Many times, they just pushed my door open and came in without saying a word or got mad at us when we were slow to respond.” (P5)

“Doctors and nurses just go through the motions without much communication or care.” (P3)

“I think no matter whether they are skilled or not, I care more about they pay attention to me and be patient with me.” (P4)

The participants told us that they thought this was because of the education system.

“It is unlikely for students to take up this occupation after graduation from college. Most people in this area are older and less educated. It’s not realistic to ask them about humanistic care.” (P1)

Need for a Family Atmosphere

Participants aspired to view the long-term care facility as their “home” and desire a familial environment. However, the absence of such an atmosphere often disrupted this idealization.

“I didn’t feel like I was treated as a family member when I moved in. If a nursing home can be like a real ‘home’, then the old people will surely be more willing to stay.” (P3)

Social Level

Interpersonal Communication Constrained by the Times

Social interaction continues to be a vital aspect for older people, with the vast majority of participants affirming its importance even though they moved into a long-term care facility.

“I’m more concerned about interpersonal communication, which I think is very significant, including talking to each other and making new friends.” (P2)

“I prefer to get out and meet close friends. . .. . .There are also colleges for older adults mentioned just now, which are more like a place for us to dance, do handicrafts, and socialize.” (P4)

And some participants expressed a preference for peer support compared to interactions with younger generations.

“We are from the same generation, talking to each other, having something in common, and more understanding each other.” (P12)

However, interactions among older adults were limited by COVID-19 pandemic, and the hit was harder for those who already perceived a lifespan.

“Even after the COVID-19 pandemic, we were still required to wear masks when meeting families and friends, which made me feel alienated from them and made me miserable.” (P3)

Inadequate Social Engagement

After the COVID-19 pandemic, long-term care facilities put more emphasis on safety management, but lacked consideration for the needs of older adults to participate in society.

“My expectation for getting out and viewing the current society and world is strong right now.” (P4)

“Since we have been restricted (in a nursing home) for three years, it would be best to drive us out to see the sights, to see what it’s really like out there now, and to get in touch with the society.” (P5)

Discussion

Integrated care policy represents an important initiative to enhance long-term care services and improve the well-being of older adults, also is one of the significant strategies of China’s “14th Five-Year Plan.” Long-term care institutions are the focal point of this policy’s changes and innovative model. This study explored long-term care residents’ perceptions and perspectives on integrated care. Using the FoC Framework, we identified the following findings: older adults had mixed feelings about the concept and implementation of the integrated care policy. They appreciated the original intent of the policy design and noted improvements in daily life care, primary medical services and overall service quality. However, they expressed dissatisfaction with advanced medical services, specialized chronic disease management, psychological support, humanistic care, and social participation.

The policy and system context, as the outermost circle of the FoC Framework, highlights the important supporting role of long-term care for older people. We found that most long-term care residents were unaware of the integrated care policy and did not understand its specific contents, making it difficult for them to recognize the services they received as contributions from the policies. This lack of awareness is often due to the absence of an information bridge between macro policies and micro individuals. Service providers at the intermediate level (institutional personnel) are considered vital in bridge this gap. ²⁴ Failure to collaboration with government staff and not having the time and support for policy advocacy work might be the barriers to service providers. ²⁵ Therefore, it is crucial to promote the relationship between government departments and long-term care facilities and provide financial compensation to service providers in order to enhance policy publicity. Other measures including holding informational lectures, producing policy promotional videos, and organizing demonstration site visits for older adults should also be applied at the organizational level as auxiliary policy support strategies. ²⁶

Another important finding of our study at this aspect was that the long-term care residents were very concerned about the LTCI. Most participants highlighted issues with the LTCI assessment process, including exploitation of loopholes and detachment from real health condition. A review of the long-term care system in China also indicated that the assessment system was controversial. ²⁷ This seemed to be a general challenge that urgently needed to be tackled. Although the Chinese government has developed a “long-term care insurance disability assessment form,” which specifies that 2 assessors are required for on-site assessment, there is no regulation regarding the role of assessors. ²⁸ Family doctors are required to be included in LTCI assessments in the United States, ²⁹ suggesting that the assessment team should include a professional caregiver familiar with the overall situation of the older person (here refers to an institutional doctor or nurse). Additionally, the inclusion of at least one disinterested neutral supervisor is also necessary.

The majority of older residents reported a high level of satisfaction with basic daily living care and primary health care services. Some other studies revealed the possible reasons that care professionals often prioritized residents’ medical needs and basic care. ³⁰ However, doctor-led advanced medical needs, nurse-led chronic disease management needs and nursing assistant-led personalized life care needs have not met the expectations of long-term care residents.

Doctor-led advanced medical needs: The most prominent issue reported was the complete restriction on antibiotic use. According to relevant policies in China, the use of antibiotics in long-term care facilities is strictly prohibited. However, our research indicated older residents were most concerned about and hoped for access to these medications. In contrast, countries like the United States, Germany, and Sweden allow the use of antibiotics in long-term care facilities. The United States has issued guidelines on promoting antimicrobial use in these settings, assigning 5 medical drug management functions to healthcare personnel.^31,32 This suggests that policymakers should reconsider the standards, guidelines, or norms for antibiotic use in long-term care institutions, and give full play to the professional role of internal medical institutions.

Nurse-led chronic disease management needs: Long-term care residents emphasized the importance of specialist care, rehabilitation training and disease monitoring services. Another qualitative study also highlighted the need for nursing homes to effectively manage chronic illnesses and provide comprehensive rehabilitation services. ³³ The prevalence of chronic diseases among long-term care residents exceeded 70%, with a co-morbidity rate of about 36% to 45%, much higher than that of older adults in community. Although the government issued institutional service guidelines in 2019, they did not include chronic disease management requirements. ³⁴ Policymakers should consider developing practice guidelines or standards for chronic diseases within institutions and require nurses to assume the primary responsibility for chronic disease management.

Nursing assistant-led personalized life care needs: Residents expected institutional caregivers to recognize their independence, respect individual needs, and respond quickly with tailored care, which is similar to the results of our study. ¹⁵ Person-centered care plans should be provided by institutional caregivers. Adequate and comprehensive pre-admission assessments are the first and most important phase of the plan, which should be demand-oriented rather than service-oriented. ²¹

Although the telemedicine platforms are a recent development driven by the Internet and big data and represent the future of smart nursing homes, ³³ our study found that residents raised concerns about privacy and confidentiality. Other studies have also pointed out that about 57% to 78% of research topics address privacy, confidentiality, and data security in telemedicine, highlighting them as significant barriers to adoption. ³⁵ The government must enact legislation on health confidentiality, data access, and provider responsibility, with clear and comprehensive oversight. The users should encrypt the data before storing the information, transmit the information through secure channels, verify the user ID before accessing the data, and add electronic signatures are considered to be effective measures to address the obstacles. ³⁶

Our study identified 2 main psychological needs among long-term care residents. One of them was the need for psychological support, especially family support. Family support was found to be positively correlated with the experience of institutionalized care for older people. Maintaining meaningful relationships is crucial, allowing older adults to connect with their families, whether they live together or not. ³⁷ The COVID-19 pandemic posed a significant barrier to the continuation of this meaningful relationship. The use of information and communication technologies, the establishment of family support groups, and the assignment of reference staff to each family are identified as viable strategies. ³⁸

Residents also expected their self-perceptions to be acknowledged, including life perception and ability perception. Our study found that even those with poor self-care abilities still strove to do what they can to take care of themselves, reduce their dependence on others, and even make contributions to society, which was also a consistent finding in other studies. ³⁹ “Retention of intrinsic capacity” is a global concern and central to integrated care. In 2017, the World Health Organization (WHO) proposed guidelines for implementing the Integrated Care for Older People (ICOPE) framework, including identification, assessment, monitoring and evidence-based practice recommendations for intrinsic capacity, which were mainly applied in communities and might be considered for institutional application in the future. ⁴⁰

The relationship aspect is the inner circle of the FoC Framework, which directly influencing the quality of care and having long-term effects. Participants in our study emphasized the importance of humanistic care, noting that institutional caregivers often failed to provide it, which made residents feel that they were not being treated like family. This sentiment was echoed in other studies, which showed that long-term care facilities often felt like shelters rather than real homes to older adults. ³⁹ Residents in our study attributed the poor provision of humanistic care to education system, and other studies identified inadequate staffing as a significant barrier. ⁴¹ Furthermore, the absence of personal items also makes the residents lack a sense of family atmosphere. ³⁷ Therefore, all the service providers involved in the care of older people should be adequately trained to develop the necessary skills, and help older residents feel well cared for and supported.^24,26 Meanwhile, replicating the home environment by moving furniture and settings from the residents’ original homes to the institution could enhance the home-like atmosphere, which is currently being piloted by a small number of institutions in some areas of China.

Our study also found that long-term care residents were increasingly experiencing social isolation and had a prominent need for social participation. Lack of socialization and disconnection of social activities were also frequently reported in previous studies. ⁴² Facility staff hold the thought that residents’ social activities were not within their responsibilities, and some even thought that social activities were unnecessary, which might be a major obstacle to the lack of social activities for older adults. ³⁰ Therefore, it is necessary for policymakers to include social interaction activities in institutional service guidelines. Institutional caregivers must participate in regular training to improve the socialization of older people, provide opportunities for social activities, and encourage residents to engage with society through re-employment, volunteering, attending university for old people, and learning about social media.

Limitations and Recommendations

There are some limitations in this study: (1) We only explored the perceptions and feelings of residents in long-term care facilities. (2) As a descriptive qualitative study of a single region with only a small sample of respondents, the generality of this study is limited. (3) Although we considered the most differentiated sample of gender factors in our study, there was still a gender imbalance.

The researchers recommend that: (1) Experiences and perspectives of older adults living in community, first-line administrators, direct professionals and informal caregivers should be explored in future studies. (2) Larger sample, especially more male participants should be included in future studies. (3) Other provinces, cities and districts should also be considered. (4) Study design and data analysis approach including grounded theory, discourse analysis and cross-sectional survey should be applicated in future studies to further explore the theoretical framework or conceptual models and integrated long-term care needs of older adults.

Conclusions

This study delves into the perceptions of long-term care residents about integrated care. In general, older people had mixed feelings about the concept and implementation of integrated care policy. They had a positive attitude and expectations about integrated care, while still some challenges on LTCI system. They praised the provision of daily life care, primary medical services and overall service quality, but complained the advanced medical services, specialized chronic disease management, psychological support, humanistic care and social participation fell short of expectations. Policymakers and healthcare providers should fully aware the unsatisfied feelings and unmet needs in integrated care practices. In conclusion, our findings may contribute to promote further improvement of the long-term care system for aged population.