XU Yifan1, JING Limei1*, LI Xueying1, LI Shuijing2
1School of Public Health, Shanghai University of Traditional Chinese Medicine, Shanghai
2Department of Primary Health, Shanghai Municipal Health Commission, Shanghai
Received: June 21, 2021 Published: september 09, 2021
*Corresponding author: ING Limei, Shanghai University of Traditional Chinese Medicine, 1200 Cailun Road, Shanghai, China. Tel: 13641635663, Emails: email@example.com; firstname.lastname@example.org; email@example.com
Shanghai, a pioneer municipal city in implementing hospice and palliative care (HPC) services in China, has realized its initial goal of universal coverage of either inpatient or home-based HPC services in all community health centers (CHCs) by 2020. However, there are still some bottlenecks during the progress, including low equalization and homogenization of services among different CHCs, and lack of charging items for comprehensive evaluation, alternative therapy, appropriate traditional Chinese medicine (TCM) technology and humanistic care which are labor-intensive. There is an urgent need to construct and standardize contents and items of HPC services and introduce payment method by service unit to encourage medical staffs to provide HPC services at all levels of care.
Keywords: Hospice and Palliative Care; Service Contents; Service Items; Payment Method
Abbreviations: Hospice and Palliative Care (HPC); Community Health Center (CHC); Traditional Chinese Medicine (TCM)
Hospice and palliative care (HPC) are a crucial part of integrated, people-centered health services, providing physical, mental, spiritual, and social care for terminal patients by controlling their discomfort . Based on the new round of HPC reform in China, Chinese National Health Commission launched two batches of national pilots in 2017 and 2019. Shanghai is a pioneer city and has devoted every effort to promote the pilot work in municipal level. With the continuous progress of pilot exploration and the improvement of acceptance of ideas, the demand of HPC is increasing nationally . Since the application of “The Implementation Plan for HPC Pilot in Shanghai (2019)”, Shanghai has realized its initial goal of universal coverage of either inpatient or home-based HPC services in all community health centers (CHCs) by 2020.
A Cross-sectional Study was designed to observe the development of HPC services in Shanghai. 246 CHCs were investigated for general HPC coverage situation, and in which 36 typical sampling CHCs were deeply investigated to analyze HPC service contents and items, payment and incentives.
Overview of HPC development in Shanghai
Shanghai, a precursor municipal city, has been giving continuous supports to push HPC research and practice, in which HPC were implemented as government project in 2012 and 2014 and increasing HPC supply from 18 CHCs to 76 health institutions including certain private nursing institutions. Whilst carrying on HPC pilot work in all 16 districts of Shanghai, “Implementation plan of HPC pilot in Shanghai” was promulgated in September of 2019. Subsequently, Shanghai HPC service model has formed with CHCs as major providers. By 2020, all the CHCs have been offering HPC services, which means the coverage rate has reached 100% . More specifically, 217 CHCs provided home-based services relying on family beds, and 106 CHCs supplied inpatient services. In addition, 98 CHCs developed both inpatient and home-based services.
General situation of HPC service contents and items in CHCs
According to “Shanghai HPC Service Specification (2020)”, a multidisciplinary team be composed to deal with complicated symptoms of terminal patients, including systematic assessment, comprehensive therapy, symptom control, comfort care, psychological support, humanistic service for both patients and their families should be provided as regular services. There were altogether 530 items provided in all investigated CHCs, with 495 charged items and 35 uncharged items included. Charged items including comprehensive medical services, clinical services, traditional Chinese medicine (TCM) services and medical technology services. Meanwhile, there were still many uncharged items existed currently, including systematic assessment, appropriate TCM technology, psychological support and social support, which were generally available and widely needed in CHCs. Particularly, many TCM services and items were available and can benefit patients as alternative and complementary supplements, which integrated Chinese characteristics into HPC.
Coverage And Accessibility Of HPC
Shanghai has achieved its initial target of universal coverage of either inpatient or home-based HPC services in all CHCs by 2020. Approximately 88.2% of CHCs provided home-based HPC services, while 43.1% provided inpatient services with independently equipped wards, 39.8% of which provided both. Meanwhile, according to WHO guideline [4-5], HPC services should be provided at all levels of care and be provided in any setting, it does not require a separate ward or department in hospitals, and efforts should be made to assure accessibility of interventions at home.
Equalization And Homogenization Among Different CHCS
Essential HPC services were broadly provided with good
availability for patients in CHCs, either physical, psychological, or
social, which was also consistent with anthor typical case study
. However, HPC services varied among different CHCs with a
low degree of homogeneity , with better availability in central
area than rural, and more comprehensive and standardized HPC
services in earlier pilot CHCs than the newly ones. Furthermore,
TCM services varied greatly among different CHCs, and each
institution carried out different services according to its own
TCM characteristic projects. Continued efforts should be made to
scientifically select certain amount of suitable TCM technology for
terminal patients and extend to all CHCs.
HPC Services Charging Status and Incentive Mechanism The primary constraint problem restricting the provision of HPC for both health institutions and health workers is lack of effective charging and payment system. Our research indicated that a significant portion of uncharged items, including TCM items, were actually carried out in CHCs. The technical labor value of health providers cannot be reflected, and fee for service was unable to motivate service provision of special services for terminal patients and their families, especially humanistic support and care. Therefore, it is urgent to explore payment by service unit, which means HPC inpatient services should be paid by hospital bed days and home-based services paid by visit times. Pay by service unit has been proved to be effective for special services like HPC [8-10], and reasonable payment standard can encourage health providers to actively participate in HPC services, especially at the stage of promoting HPC at all levels of care.
In summary, HPC services have been actively carried out in Shanghai. However, there were still significant differences among various CHCs, and lack of labor-intensive charging items was unable to effectively impel health providers. There is, therefore, more efforts should be made to promote the regional equalization and institutional homogenization, and pay by service unit and relevant incentive policies are urgently needed to promote HPC providing at all levels of care.
This study was supported by grants from Pujiang Talent Program of Shanghai(2019PJC099), Humanities and Social Science Research Planning Fund of the Ministry of Education(20YJAZH045).
No Conflict of Interest.
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