Abstract
Background
There is a large demand gap for home-based medical services. Understanding the characteristics of people in need of services can help provide relevant services more effectively and accurately.
Objective
To understand the health status categories and characteristics of home-based medical services for older patients with chronic diseases.
Methods
A cross-sectional research method was used to investigate the self-reported service needs and health status of 371 older patients with chronic diseases from four areas: environment, psychosocial, physical, and health-related behaviors. K-means cluster analysis was used to classify the population, and variance analysis was used to examine the basic characteristics of different categories of patients.
Results
Only 191 patients self-reported needing home-based medical care and were divided into three clusters: outstanding demand for psychological services, comprehensive health services in demand, and continuous optimization of health levels. There were statistically significant differences in the education level, economic status, health status, living conditions, and cohabitation status of the three clusters of patients (P < 0.05).
Conclusion
The home-based medical service needs of community-dwelling older adults with chronic diseases may vary based on education level, economic status, and health status. How to provide appropriate services according to educational background, economic status and health status is a service topic that needs to be studied in the future.
Keywords: Home-based medical services, Demand, Characteristics, Chronic diseases, Cluster analysis
Introduction
With the rapid development of the social economy and medical level, human life expectancy continues to increase, the population ages, the number of children decreases, and the disease spectrum shifts to chronic noncommunicable diseases, making geriatric care and medical care important social issues [1]. According to its Global Strategy and Action Plan on Aging and Health, the World Health Organization emphasizes the importance of providing home and community care to ensure that older people can “live with dignity” [2]. Home-based medical services have become one of the recognized solutions for solving these social problems and achieving healthy aging [3, 4]. “Home-based medical services, that is, services provided by institutional medical staff according to the needs of specific groups, especially the older patients [5], have become a priority for the development of countries around the world [6]. In this study, home-based medical services are defined as formal medical services provided to patients at home by qualified medical staff.
Home-based medical services have well-established service systems and models in most countries. However, in China, it is still in the exploratory stage due to its late start. In China, home-based medical services mainly include five forms of home services provided by social forces such as nurses’ stations, continued care provided by general hospitals, family doctor contract extension services and pilot reform projects of home medical services provided by community health service centers and township health centers, and online booking and offline services provided by the Internet +. The services cover medical care, rehabilitation training and hospice care [3]. And at present, the provision of home-based medical services is mainly determined by patients’ wishes.
Home-based medical services are facing the challenge of the growing diverse needs of older chronic disease patients and disabled patients, as well as imperfect and inadequate home-based medical service systems [3, 7], which leads to service erection barriers or service surpluses in the agency and failure to meet patients’ needs [8]. A report from Deng showed that 51.5% (2667/4093) of older patients whose demand for home visits was unmet and 54.6% (2841/3549) whose demand for psychological counselling was unmet [9]. In response to these challenges, many scholars have proposed the concept of ‘demand-oriented’ resource integration-based home-based medical services [10], that is, the classification and triage of patients on the premise of promoting the rational allocation of resources, and its effectiveness has been demonstrated in the management of patients with chronic diseases [11]. Therefore, evaluating and clarifying patients’ medical support and needs in China has become a significant topic of discussion.
Based on the viewpoint of the Andersen’s behavioral model, needs are categorized into perceived needs and evaluative needs based on individual characteristics [12]. Perceived needs refer to individuals’ subjective experiential judgments of their health status. Assessment needs, on the other hand, involve professional judgement and objective measurement of the patient’s physical condition and medical care needs by doctors in clinical practice [13, 14]. Research on the demand for home-based medical services varies significantly between domestic and international studies. Countries such as the USA and Canada have developed well-known tools such as the Easley-Storfje patient classification instrument [15, 16], the RAI-HC [17, 18], and the CHIRS [19–21] for assessing patients’ health problems and determining their needs. In China, studies have mostly focused on the specific types of services or programs in which patients self-reported their needs, and the content reported by different scholars has varied. For example, Wang’s study showed that older patients in the Beijing Chaoyang District self-reported that most needed blood pressure measurements, teaching caregiver knowledge, glucose monitoring, and nursing safety education services [22]. Another survey of older patients in Beijing showed that patients most needed psychological counseling, medication guidance, and disease-related knowledge education [23]. Although the expression of the precise need is more conducive to providing personalized services, it is not enough to provide an effective basis for the macro management of patient diversion.
The Omaha system, as a system for identifying patient health problems, delivering intervention plans, and evaluating effectiveness, is used in many settings, including community care, continuing care, and clinical care [24]. This system includes 42 health issues in four areas: environmental, psychosocial, physiological, and health-related behavior [25]. Given that this scale can objectively assess and identify patients’ health problems, and in the context of rising patient demand and limited service availability, this study was based on self-reports of older patients with chronic diseases and used the Community Health Intensity Rating Scale (CHIRS), which is based on the Omaha System, to conduct a professional assessment of patients, and made use of the above two result, to determine and classify the home-based medical services of older patients with chronic diseases, and analyze the characteristics of different categories of patients in depth. To assist clinical personnel in predicting health issues and home-based medical service needs and content based on population characteristics and to further provide a basis for patient management and matching targeted services.
Clinical implications
Clinical personnel should identify chronic population characteristics for different categories of health problems to help quickly classify patients, classify health issues among people with chronic diseases for efficient patient management, and provide a home-based medical service evaluation tool, providing a basis for the rational supply of services.
Method
Design and setting
The data for this study come from a survey project on the demand for home-based medical services. This was a cross-sectional study to conduct a door-to-door survey on the home-based medical service needs of older chronic disease patients in Wuhou District, Chengdu, Sichuan Province from April to November 2021.
Participant
Yulin Community Health Service Institution is the clinical teaching and practice base of West China Hospital, Sichuan University. This study screened and included participants from this institution. The individuals included in this study were diagnosed with at least one chronic disease and had received chronic disease health management from a community health service center. The participants also met the following inclusion criteria: ⅰ) aged 65 or above; ⅱ) lived at home; ⅲ) were older individuals who indicated that they needed care or had difficulty moving on the phone; and iv) were willing to complete the survey and sign the informed consent, and if the patient was cognitively impaired, the consent of the caregiver who had legal representation was needed. Patients who used services in community daycare institutions were excluded.
Sample size
According to the sample size equation of the cross-sectional survey design N = (Uασ/δ)2, α was 0.05, and Uα was 1.96. To enroll as many participants as possible, the standard deviation σ was 4, which came from the original scale scored in patients (25.4 ± 4.0) through a literature review, and the δ used 0.5 points, calculating and obtaining 246 individuals. After expanding 1.5 times [25], the sample size should be at least 369.
Instrument
This study included a general information questionnaire and the C-CHIRS. The general information questionnaire included basic information on patients, such as age, sex, and disease incidence, which is self-designed on the basis of literature review. The C-CHIRS is a translation and revision of the Community Health Intensity Rating Scale (CHIRS). CHIRS was developed by the American scholar Donna Ambler Peters in 1989 based on the problem classification subsystem of the Omaha System. It is used by healthcare professionals to evaluate the health status of community residents and determine their level of health. The evaluation content of this scale includes four domains, namely, the environmental domain (including two dimensions of economic and physical environment), the psychosocial domain (including four dimensions of community networks, family systems, emotional/psychological reactions, and personal growth and development), physiological functional domains (including 6 dimensions of perceptual function, respiratory/circulatory function, neuromuscular skeletal function, reproductive function, digestive/excretory function, and structural integrity) and health-related behavior domain (3 dimensions of nutrition, personal habits, and health management), which have a total of 83 specific indicators across 15 dimensions. Each dimension represents the highest score of each indicator. The higher the score is, the more significant the patient’s health problems are in this dimension [19, 20, 26]. The scale has been used to assess the health level of infants, older adults, people suffering from AIDS, and other community groups and their demand for medical care services and has also been extended to schools to determine the degree of student demand for school health services [27]. After authorization from professor Donna Ambler Peters, we sinicized the scale and reported the sinicization process [10]. At the same time, we also used the scale to screen the need intensity for home-based medical services among older patients with chronic diseases in a district of Sichuan Province, and published elsewhere [28].
Participants recruitment and data collection
The study’s participant recruitment consists of three phases: Community family doctors of Yulin Community Health Service Institution involved in the joint project screen patients based on criteria and compile lists, researchers then contact patients by phone to explain the study’s purpose and methods, and arrange and conduct surveys after securing patients’ informed consent. All data are collected by a registered nurse during home visits to patients. Basic information is retrieved from the health system prior to the visits. C-CHIRS data are obtained through observation, interviews, etc. The questionnaire requires 50–75 min to complete, and researchers also offer health guidance during the survey.
Ethics considerations
The study protocol was approved by the Biomedical Ethics Committee of West China Hospital, Sichuan University (Number: 2020 − 165) and all the participants provided informed consent for this study. The study was conducted in strict accordance with the Declaration of Helsinki [29], the protocol and the regulations of West China Hospital of Sichuan University.
Statistical analyses
SPSS Version 25.0 was used for all the data analyses. The criterion for statistical significance was set at P < 0.05. The proportion was used to describe the general data of patients, such as sex, age range, and education. The K-means method was used to categorize the population based on the individual variables (four-dimensional scores of the CHIRS) of the participants compared to other clusters. The principle closest to the center of the particular cluster (the overall average) divides the participants into a cluster. To calculate standardized scores for four dimensions of environmental, psychosocial, physiological, and health-related behavior. The k values of 2, 3 and 4 were selected for clustering. After clustering, ANOVA analysis of variance was used for verification. At the same time, the general characteristics under different K values were statistically analyzed, and K was finally determined to be 3.
Results
This study included 371 patients ultimately, and 191 (51.48%) of them self-reported a need for home-based medical services.
General information
Among the 191 patients with chronic diseases, 99.48% (190) were of Han nationality. The age range was 65–101 years, with an average of 85.12 ± 7.084 years (Table 1). Among the 191 patients, there was an average of 3.32 ± 1.376 chronic diseases, ranging from 1 to 7, and hypertension and diabetes were the most common.
Table 1.
General information of the patients (n=191)
| Variables | n (%) | Variables | n (%) |
|---|---|---|---|
| Gender | Floor and elevator | ||
| Male | 83(43.45) | ≥2floors with elevator or first floor | 90(47.12) |
| Female | 108(56.54) | ≥2 floors without elevator | 101(52.88) |
| Age | Types of cohabitants | ||
| 65-74 | 13(6.81) | Live with spouse only | 68(35.60) |
| 75-89 | 122(63.87) | Live with nanny | 48(25.13) |
| ≥90 | 56(29.32) | Live with a family of non-spouse | 56(29.32) |
| Education level | Live alone | 19(9.95) | |
| Senior school or below | 74(38.74) | Types of caregivers | |
| High school | 71(37.17) | Care by a spouse only | 67(35.08) |
| College | 46(24.09) | Care by carer | 52(27.23) |
| Marriage | Care by a family of non-spouse | 43(22.51) | |
| With spouse | 125(65.45) | Self-care | 29(15.18) |
| Without spouse | 66(34.55) | Types of medical insurance | |
| Personal monthly income(yuan) | Basic medical insurance only | 61(31.94) | |
| ≤2,500 | 18(9.43) | Basic and supplementary insurance | 109(57.07) |
| 2,501-5,000 | 91(47.64) | Free medical services | 21(10.99) |
| ≥5,001 | 82(42.93) | Current health status | |
| Household monthly income(yuan) | Good | 18(9.42) | |
| ≤2,500 | 12(6.28) | Fair | 64(33.51) |
| 2,501-5,000 | 108(56.55) | Poor | 109(57.07) |
| ≥5,001 | 71(37.17) | Change in Health Status | |
| Number of chronic illnesses | Worse | 117(61.26) | |
| 1 | 15(7.85) | Similar | 57(29.84) |
| 2 | 42(21.99) | Better | 17(8.90) |
| 3 | 55(28.80) | ||
| ≥4 | 79(41.36) | ||
Cluster profiles
The clustering results revealed 37 patients in Cluster 1, 95 patients in Cluster 2, and 59 patients in Cluster 3, accounting for 19.37%, 49.74%, and 30.89%, respectively, of the total number of people who needed home-based medical services (Fig. 1). According to the results of standardized score clustering, the three types were successively named outstanding demand for psychological services, comprehensive health services in demand, and health level continuous optimization.
Fig. 1.
Results of K-means cluster analysis
Differences among the three clusters Variance analysis or Welch’s test was used to analyze the basic characteristics of patients with different types of health status (Table 2). The results showed that education, travel conditions, type of residents, individual and family monthly income, and type of health insurance were significantly different among the different clusters (P < 0.05).
Table 2.
Analysis of differences in the general data among the three clusters (n=191)
| Variables | Cluster | F/Welch | P | ||
|---|---|---|---|---|---|
| 1 | 2 | 3 | |||
| Education level | 7.713 | 0.001 | |||
| Senior school or below | 6(16.22) | 39(41.05) | 29(49.15) | ||
| High school | 15(40.54) | 35(36.84) | 21(35.59) | ||
| College | 16(43.24) | 21(22.11) | 9(15.25) | ||
| Floor and elevator | 3.287 | 0.042 | |||
| ≥2floors with elevator or first floor | 16(43.24) | 46(48.42) | 39(66.10) | ||
| ≥2 floors without elevator | 21(56.76) | 49(51.58) | 20(33.90) | ||
| Types of cohabitants | 6.222 | 0.002 | |||
| Live with spouse only | 24(64.86) | 28(29.47) | 16(27.12) | ||
| Live with carer | 5(13.51) | 24(25.26) | 19(32.20) | ||
| Live with a family of non-spouse | 6(16.22) | 32(33.68) | 18(30.51) | ||
| Live alone | 2( 5.41) | 11(11.58) | 6(10.17) | ||
| Personal monthly income | 5.649 | 0.004 | |||
| ≤2,500 | 2( 5.41) | 5( 5.26) | 11(18.64) | ||
| 2,501-5,000 | 12(32.43) | 50(52.63) | 29(49.15) | ||
| ≥5,001 | 23(62.16) | 40(42.11) | 19(32.20) | ||
| Household monthly income | 3.966 | 0.022 | |||
| ≤2,500 | 1( 2.70) | 7( 7.37) | 4( 6.78) | ||
| 2,501-5,000 | 16(43.24) | 52(54.74) | 40(67.80) | ||
| ≥5,001 | 20(54.05) | 36(37.89) | 15(25.42) | ||
| Types of medical insurances | 12.917 | <0.001 | |||
| Basic medical insurance only | 6(16.22) | 37(38.95) | 18(30.51) | ||
| Basic and supplementary insurance | 26(70.27) | 48(50.53) | 35 (59.32) | ||
| Free medical services | 5(13.51) | 10(10.53) | 6(10.17) | ||
| Current health status | 12.917 | <0.001 | |||
| Good | 10(27.03) | 5( 5.26) | 3( 5.08) | ||
| Fair | 16(43.24) | 35(36.84) | 13(22.03) | ||
| Poor | 11(29.73) | 55(57.89) | 43(72.88) | ||
Discussion
This study aimed to evaluate the demand types and characteristics of older patients with chronic diseases who needed home-based medical services. The results showed that patients were divided into 3 clusters, and the significant differences were in their education level, type of cohabitant, income, type of medical insurance, and current health status.
This survey revealed that only half of the patients needed home-based medical services, which is significantly different from the demand rates reported in previous Literature of 85.6%−98.1% [21, 30, 31]. Due to the convenience of inclusion in the patient survey, all patients interviewed in this study were managed by community health service institutions for chronic diseases, and they received chronic disease management services provided by the institutions, including regular physical examinations, indicator monitoring, medication management, and health guidance [32]. Although the rate of need for home-based medical services in this study is relatively low compared to that reported in the literature, there is still demand among patients who have received management from community health institutions, which also indicates the necessity and incompleteness of conducting home-based medical care services.
K-means clustering analysis revealed that the three clusters exhibited significant differences. Compared to clusters 1 and 2, Cluster 3 has relatively prominent health issues and medical needs in all four domains, among which health-related behaviors and physiological fields are particularly noteworthy. In contrast, Cluster 1 shows less significant health issues in all four domains. Cluster 2 is unique due to its significantly greater demand in the psychosocial domains compared to health issues in the three domains, indicating that the psychological and social health status of patients in this cluster needs to improve.
The sociodemographic characteristics of the patients showed significant differences among the three clusters. The results of the analysis of variance showed that patients in cluster 1 had a greater cultural background, while patients with higher education levels had greater awareness and ability to obtain health information and further adopted behaviors to maintain health [33, 34]. At the same time, people who receive good education often have greater economic benefits. A good income level not only provides a sufficient material basis for them to adopt a healthier lifestyle and create a healthy living environment but also provides a solid payment and reimbursement guarantee for their access to medical services [35]. Previous studies have reported that patients living with their spouse as family members have better mental health [36], and the mental health level of non-empty-nest older person is greater than that of empty-nest [37]. However, a survey by the Chinese scholar Zhu revealed that the older people living with their spouse have weaker feelings of loneliness and greater levels of happiness [38], which may be due to family members being busy with work and caring for the next generation for non-spouse descendants, even if Living together, the actual companionship is insufficient. This may also be one of the reasons why patients in Cluster 1 of this study showed healthier states and fewer health problems in the field of psychosocial well-being, and further research is needed to confirm this result. Shafiee’s research showed that education level, high economic income, and insurance are associated with successful aging, but it is necessary to continuously maintain and improve health habits to promote a longer lifespan [39].
In this study, cluster 1 patients reported that their current health condition was good, but they still needed home medical services to obtain a healthier state. Undoubtedly, this population is more likely to achieve healthy aging with the support of medical services, thanks to their good information reception ability and medical funding guarantee. Home-based medical care services also play a unique role in achieving higher levels of health. The “Internet +” home-based medical service is gradually being promoted in China, driven by its diverse service offerings, instant booking capabilities, and convenience. However, the relatively high cost of these services means they are more suitable for individuals with a certain level of economic strength and educational background, as well as those with higher health requirements [40]. For cluster 1, the “Internet +” home-based medical service demonstrates better adaptability.
According to the clustering analysis results, Cluster 3 showed a polarization with Cluster 1, and the patient population showed significant health problems in all four fields; these patients also had the worst cultural level, economic income, and health status. Due to relatively poor health conditions, most patients reside on the first floor or in houses with elevators for transportation. Patients in Cluster 3 are more likely to require comprehensive home-based medical services due to poor health conditions, but their economic income and ability to bear medical costs are relatively limited. Therefore, home-based medical services for this population may also need to be protected and supported by national policies and health institutions. In fact, the government’s pilot project of long-term care can just fill the needs of this population, although the service content is mainly some life care, supplemented by a few formal home-based medical services, but the local government provides additional subsidies in cash and other ways to ensure their access to other health services [41].
Cluster 2 is located between Cluster 1 and Cluster 2, with a moderate degree of health issues, and it is also difficult to distinguish between the patients in Cluster 1 and Cluster 2 in terms of sociodemographic characteristics. The patients in this cluster had a moderate level of education, economic status, and health status. Among the four fields, psychological and social health issues are relatively more prominent compared to the other three. An analysis of the types of cohabitants revealed that patients in cluster 2 mostly cohabited with non-spouse family members and spouses, while patients in cluster 3 mainly Lived with nannies and non-spouse collective members. Therefore, there were more health issues in the psychological field in the two clusters than in cluster 1, but there were differences between them. Overall, this population has relatively prominent psychological and social health issues while also having a certain purchasing power for medical services. Therefore, home-based medical services focus on providing services that help improve the level of psychological and social health, which is highly important for improving patient health and reducing medical costs for this population. Family doctor contract extension services in community health service centres and continued care provided by some general hospitals may be better able to meet the needs of such patients.
Advantages and limitations
The strength of this study is the use of semi-interviews to ensure the authenticity of the data collection as much as possible. This study also has several limitations. First, for the convenience of investigating patients, this study included patients who received chronic disease management from community health service institutions. Therefore, the results of the study cannot represent patients who did not receive relevant chronic disease management. Future research should pay more attention to the representativeness of the sample. Second, this study categorized patients in a general manner based on the four domain scores of the Omaha system without further refining the patients’ health issues. The next step should be to address more specific health issues to better clarify patients’ home medical service needs and content.
Conclusion
Most patients who receive community-based chronic disease management still need home-based medical services. The sociodemographic characteristics of these patients can be divided into three categories: those with strong health-seeking behavior awareness and purchasing power, those with poor health status and purchasing power, and those with prominent psychological and social problems in purchasing power. Combining patient characteristics can help identify patient population categories and health needs and provide a basis for the implementation of home-based medical services.
Acknowledgements
The author would like to thank the Sichuan University West China Nursing Discipline Development Special Fund and thank Professor Donna Ambler Peters for authorizing the Chinese version of CHIRS. The authors also wish to acknowledge all patients for their participation.
Authors’ contributions
Suzhen Liu designed the study. Suzhen Liu and Hang Li completed the data collection. Hang Li analyzed the data and wrote the main manuscript text. Suzhen liu and Qiying He reviewed and modified the manuscript. All authors reviewed the manuscript.
Funding
This work was supported by the Sichuan University West China Nursing Discipline Development Special fund (grant numbers HXHL19018).
Data availability
The data cannot be made public for privacy reasons. A reasonable request to reuse the data can be submitted to the corresponding author.
Declarations
Ethics approval and consent to participate
The study was reviewed and approved by the Biomedical Ethics Committee, West China Hospital, Sichuan University (approval number: 2020-165). All participants were informed of the purpose and content of the survey.
Competing interests
The authors declare no competing interests.
Footnotes
Publisher’s Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
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