Integrated institutional care based on comprehensive assessment–a case study of Yanda Long-term Care Centre in China

Introduction: Long-term elderly care institutions in China usually solely provide care for daily living to the residents. In response to the multiple needs of the elderly and the policies of integrating health and care by the government, some elderly care institutions started exploring new care models.Yanda Long-term Care Centre is a private institution with more than 5000 beds participating in the interRAI initiative in China. Partnering with a built-in community health care center, it explored integrated institutional care based on interRAI assessment. Practice change implemented: The Centre has established a service model of ""integrated multidisciplinary care based on comprehensive assessment"" to provide integrated health and social care for the elderly. The main concept of the model is to provide comprehensive and effective care through care management and multi-professional teamwork. This care model started its official operation in 2010 and the development is ongoing. Targeted population and stakeholders:The targeted population is all residents in the center especially those with disability or other chronic conditions. Key stakeholders include the management team of the facility, the case managers, the multi-disciplinary care team, the interRAI company in China and the residents’ families. Highlights Yanda Long-term Care Centre adopted a three-tier assessment model. A basic ADL assessment was conducted as initial screening, with disabled residents entering into the next comprehensive assessment which used Long Term Care Facility Assessment Scale (InterRAI-LTCF) as the tool. Specialist assessment scales measuring functional, cognitive, nutritional, spiritual and other dimensions will be employed for specific conditions, such as mini nutritional assessment (MNA), Braden scale for predicting pressure score risk etc. The case managers are responsible for assessing the needs of the elderly and the quality of long-term care services, developing and guiding the implementation of integrated long-term care plans, integrating care resources. Multi-disciplinary care team supported by the built-in community health center，include physician, nurse, therapist, nutritionist, pharmacist, physical and occupational therapist , social worker and so on. They provide comprehensive services, including medical, nursing and rehabilitation services, health management upon needed. Comments on sustainability and transfer-ability: The service model could be sustainable if the current management team of the facility remains stable. The service procedures, assessment methods, case management and multidisciplinary team formation based on the built-in health care center all provide valuable experiences for other elderly care facilities to learn and practice in China. Discussion: Despite progress made, there are still some barriers, including the lack of training systems for professional assessors, underdevelopment of the insurance system for integrated long-term care services. Conclusion: The model develops individualised service plans based on comprehensive assessment and establishes a case management system, providing integrated interventions and services to high-needs residents. It reduces the incidence of risk, improves residents’ quality of life and acquires high satisfaction from both residents and their families. Attention should be given to a more standardised implementation pathway for comprehensive assessment, cultivation of professional talents and further development of financing and payment systems for integrated long-term care services.