Medical and Old-Age Care Integration Model and Implementation of the Integrated Care of Older People (ICOPE) in China: Opportunities and Challenges

Abstract

The demand for healthy old-age care is growing rapidly in China. The traditional old-age care model can no longer meet elderly patients’ demands for medical care and old-age care. To promote the development of medical care-integrated old-age care, a solution covering multiple aspects is necessary. In the context of the global development of healthy aging, China recently issued many policies to integrate old-age care with medical care, establishing protection for a large number of disabled elderly people. The Integrated Care of Older People (ICOPE) project is an international program developed by the World Health Organization. This paper reviews China’s medical and old-age care integration model and the opportunities and challenges in implementing the ICOPE in the context of healthy aging in China.

Chinese life expectancy is increasing with modern demographic transition and continuous improvement in the country’s socioeconomic development (1). By 2019, the average life expectancy reached 77.3 years, with population aging becoming one of China’s most distinctive social features (2). According to the United Nations report, the number of 60-year-olds is projected to exceed 400 million by 2035 and reach 500 million by 2055 in China (3). The risk of disease is increasing rapidly with population aging and lifespan extension, thereby putting pressure on families and society to allocate resources for healthcare, rehabilitation, and old-age care. The World Health Organization (WHO) introduced the concept of healthy aging, to draw more attention to the health status of elderly populations and the corresponding healthcare development, extend the healthy lifespan of elderly people, and help them maintain a better health status. Healthy aging is among the key frontiers for twenty-first century geriatrics and gerontology and has become an important global strategy to deal with population aging (4, 5). China has made remarkable progress in strengthening its primary health-care system (6). Under the background of The United Nations Decade of Healthy Ageing (2021–2030) (7), an integrated care action on healthy ageing in China is urgently needed. Recently, WHO formulated a person-centered approach, Integrated Care for Older People (ICOPE) (8). This paper reviews China’s medical and old-age care integration model and integrated care in the context of healthy aging.

China’s population aging and medical and old-age care integration

The old-age care model implemented in China is mainly the “9073” plan—that is, about 90% of elderly people are taken care of by their family members, with children and spouses being the main caregivers. However, the caregivers lack old-age care knowledge, resulting in a scenario where disabled elderly people do not have access to medical care, and the facilities for home-based old-age care are inadequate, thereby compromising their care. In addition, there are more than 200 million one-child families in China, resulting in an increasing number of “4-2-1 family”—that is, “four elderly people, one couple, and one child” per family, thereby placing heavier old-age care burdens on young couples. For this reason, the traditional home-based old-age care model is facing huge challenges. In 2015, China’s one-child policy was replaced by a universal two-child policy to meet the social, health, and care needs of the elderly population (9). In 2013, the State Council of China promulgated the “Opinions on Accelerating the Development of Old-age Care Industry,” formally issuing a national policy for medical and old-age care integration. As stressed by the “13th Five-year Plan for the Development of National Undertakings for the Aged and the Construction of the Old-age Care System” of the State Council, it is necessary to further develop health management services that not only integrate medical and old-age care but also meet the diverse needs of elderly people, to promote healthy aging. Medical and old-age care integration refers to integrating medical care, rehabilitation, nursing, and life care to meet the needs of elderly people, and is an effective means to improve the quality of old-age care.

China’s exploration of a medical and old-age care integration model

China has been implementing a series of measures to actively respond to population aging and provide equitably accessible and systematically continuous healthcare to all throughout the life cycle. In the past 10 years, China has made substantial progress in improving equal access to care (10). In 2013, the concept of “medical and old-age care integration” was formally introduced in a policy document, to actively promote the integration of old-age care with medical care in the future development of the old-age care industry. Since then, policies on this concept have been increasing. In 2016, China issued “Outline of Healthy China 2030,” the first nationallevel medium- and long-term strategic health plan, clearly establishing “Health for All” as the fundamental objective of building a healthy China. The plan advocates focusing on the entire population and complete life cycle to respectively ensure equitable access and systematic continuity of healthcare for achieving health for all at a higher level.

In 2017, the General Office of the National Health and Family Planning Commission (hereafter “the General Office”) issued the “Notice of the General Office of the National Health and Family Planning Commission on Division of Key Tasks for the '13th Five-Year’ Healthy Aging Plan,” specifying the strategies, actions, and goals of the Healthy China 2030 plan; these include vigorous development of integrated medical and old-age care, promotion of long-term home-based care for elderly people, and launch of demonstration projects for medical and old-age care integration.

In April 2019, the State Council issued the “Opinions of the General Office of the State Council on Promoting the Development of Old-age Care” to (1) continue to improve the old-age care system that is based on homes as the basic units, supported by communities, supplemented by institutions, and operated under a medical and old-age care integration model; (2) establish and improve a long-term care system for healthy elderly people and disabled elderly people; and (3) strengthen the service management system that is centered on credibility and guarantees provision of quality services under decentralization and centralization; the aim is to ensure that, by 2022, every elderly person has access to basic old-age care, and their needs for diverse and multi-level old-age care are met, with significant improvement in the sense of acquisition, happiness, and security of elderly people and their children.

In October 2020, the General Office of the National Health and Family Planning Commission issued the “Notice on Issuing the Guidelines for Management of Integrated Medical and Old-age Care Institutions (Trial),” specifying management requirements for (1) integrated medical and old-age care institutions; (2) old-age care; (3) medical care; and (4) the coordination, operation, and safety of medical and old-age care.

Medical care-integrated old-age care, as a new old-age care model, combines medical, nursing, and basic old-age care facilities with life care, barrier-free activities, and other relevant old-age care services. In other words, it integrates medical resources with those of old-age care, with the former referring to the provision of medical services such as preventive healthcare, diagnosis and treatment, rehabilitation care, and hospice care, and the latter covering all aspects of life such as life care, social participation, cultural activities, and leisure and entertainment. This new model attaches higher importance to elderly people’s physical health and the quality of medical and nursing services provided to them, further meeting their needs for medical care, nursing, and old-age care in their later years. In Beijing, for example, according to the Beijing Special Plan for Old-age Care (2018–2035), 80% of elderly people with household registration will have access to nearby, precise, and expected old-age care by 2025. By 2035, 100% of the elderly population will be provided with basic old-age care, and all elderly people with disabilities and dementia will receive quality long-term care.

However, the medical care-integrated old-age care model has been advocated only in recent years. Due to China’s large base population and the gap between urban and rural areas, elderly people in some areas still lack access to adequate medical care, which restricts the integration of medical and old-age care. At the initial stage, the institutions of medical care-integrated old-age care lack a perfect internal management model, making their services less satisfactory and, thus, highlighting the need to strengthen team building in this integration. There are also some caregivers who lack professionalism and are not well-trained, generally relying on experience in performing their tasks. The lack of caregivers with professional nursing skills results in elderly people being provided with only basic care, while the needs of those with disabilities and dementia for diverse and professional care are not met. In addition, the policies on medical and old-age care integration for functionally declining and functionally intact elderly people are not sufficiently detailed and are poorly implemented, only specifying a limited range and variety of services, thereby failing to meet the needs of the large non-disabled elderly population.

Healthy aging and ICOPE

The 2016 WHO “Global Report on Aging and Health” re-defines healthy aging as the process of developing and maintaining the functional ability elderly people require to live a healthy life (11). Functional ability is the health-related attribute that enables individuals to live and act in accordance with their own perceptions and preferences; it comprises three parts: (1) intrinsic capacity, (2) environment, and (3) the interaction between the two. Intrinsic capacity refers to the composite of all physical and mental capacities that an individual can use at any given time. Environment refers to all the factors in the outside world that form the context of an individual’s life, including families, communities, and society. Healthy aging reflects continuous interactions between the individual and environment, which result in trajectories of both intrinsic capacity and functional ability (12).

According to the new theoretical model of healthy aging, maintaining intrinsic capacity and providing environmental support are the basic means to maintain and promote the functional ability of elderly people—although their intrinsic capacity and functional ability will decline with age, their choices and interventions at different stages of life will determine their individual specific trajectory. Access to more effective care and basic medical services can delay the decline and may even improve their intrinsic capacity, leading to a healthier aging trajectory.

The WHO issued the “Global Strategy and Action Plan on Aging and Health” to adapt the health system and services to the needs of elderly people for ensuring that society’s response to population aging is consistent with the goals of the 2030 Agenda. The WHO also formulated ICOPE, which is a guide to person-centered assessment and management pathways in primary care, based on the principle that the functioning level of elderly people is maximal when services and systems integrate health care and social care in a manner that takes their specific needs into consideration (i.e., a person-centered approach) (8). Integrated care has been widely used to improve health outcomes and system efficiency, especially for elderly people and those with chronic health issues. To implement the ICOPE, WHO proposes to follow the trajectory of each individual’s intrinsic capacity, which is the composite of all their physical and mental capacities and comprised of the following five domains: mobility, cognition, vitality, sensory and psychological state (8). Several essential actions required to implement the ICOPE program at system and service levels have been scheduled by WHO (13). In order to implement the WHO ICOPE program, France launched the INSPIRE program to build a Bio-resource Research Platform for Healthy Ageing gathering biological, clinical and digital resources in the Occitania region, which further promote healthy aging and maintain the autonomy of seniors using digital medicine (14, 15, 16).

China has started the ICOPE-CHINA programme to provide integrated and diversified services to meet the clinical, rehabilitation, care, and psychological needs of elderly patients by promoting the combination of community home care and medical care; the aim is to achieve individualized, standardized, and comprehensive diagnosis and intervention for elderly patients. As a first step to implement ICOPE, the WHO ICOPE screening tool was validated in Chinese older population (17). With the rapid development of 5G, the Internet, the Internet of Things, big data, and other technologies, the development of intelligent old-age care will inevitably embrace breakthrough innovations, which will allow full use of “Internet+” to enable elderly people to manage their health right till the end. It is advisable to use cloud computing, big data, and other technologies to build community and family health service platforms for not only providing elderly health management services such as real-time monitoring, long-term tracking, health guidance, evaluation, and consultation but also developing various diagnostic terminals and rehabilitation equipment for primary healthcare institutions and community homes. The ongoing key R&D program of the Ministry of Science and Technology—“Application Demonstration of Crossover Services in Healthy Old-age Care”—intends to provide highly informative and intelligent crossover services for old-age care.

Conclusion

Geriatric medicine is an old but emerging subspecialty in China (18). The government has conceived strategies to channel the dynamics of aging toward further social progress (19). Development of an integrated care system is the only way to achieve healthy aging, and it is also the main direction for the future development of China’s old-age care industry. In recent years, China has made significant progress in the polices on medical and old-age care integration in terms of quantity, coverage, and depth. This integration has achieved remarkable results in many regions, providing more reliable care and medical protection to many disabled elderly people. Therefore, in view of the growing trend of population aging, China should incorporate the WHO’s new concept of healthy aging in its existing model of medical care-integrated old-age care to develop person-centered, integrated care that enables elderly people to better enjoy their later years, as well as helps achieve a healthy aging society.

Conflict of Interest

The authors have no conflict of interest to report.