Whole systems care for post-stroke management in older adults: exploring the options for integration of health and social care systems in China

As a result of social and economic change over the past few decades, a number of low- and middle-income countries have rapidly ageing populations who are more vulnerable to long-term health conditions. To date, there has been little exploration of how the experiences of high-income countries that have developed models of integrated health and social care might inform strategies in low- and middle-income countries with growing numbers of older adults. This development grant seeks to build evidence towards development of a stroke care system for older adults in Guangdong Province, China. China's population is rapidly ageing, and approximately half of adults over 60 are living with chronic diseases. High blood pressure is the main risk factor for stroke which is leading cause of death and disability in the country. Family structures, levels of social support, and access to health insurance for older adults have changed due to the 'one-child policy', internal migration, and health reforms since the late 90's. Older adults in rural and urban settings have different levels of health awareness and support and seek health care differently, but overall, the care they receive is inconsistent and patchy. This project focuses on stroke care to explore how health and social systems are working to enable or hinder continuity of care for older adults with chronic disease conditions. First, we aim to distil the lessons learned from the international literature on stroke systems of care for older adults and examine their applicability in the Chinese health systems context. Second, we will conduct field research involving data collection with older adults, lay caregivers, and professional health and social care providers in an urban and a rural prefecture of Guangdong Province (Guangzhou and Meizhou respectively) to document experiences, patterns of care-seeking, and perceived needs for chronic disease management. A specific focus on stroke patients' journeys through recovery and rehabilitation will allow us to identify how the systems currently work, and to what extent they hinder or facilitate integrated care. Third, we will examine and summarise the data collected in the form of a model that illustrates how health and social care systems currently respond and interact to meet the needs of older patients who are recovering from a stroke. Finally, we will disseminate results through a participatory workshop that includes key individuals from health and social care institutions in order to discuss and make recommendations regarding the potential strategies that can integrate elements of current health and social care systems to improve the care of older stroke patients. This work will inform the development of a larger proposal that can implement and evaluate one or more of the strategies identified to support development of a stroke care system in China.

This development grant seeks to build evidence towards development of a stroke care system for older adults in Guangdong Province, China. China's population is rapidly aging, and approximately half of adults over 60 are living with non-communicable diseases. This project uses the tracer of stroke care to explore how health and social systems enable or hinder continuity of care for older adults with chronic disease conditions. First, through a scoping review, we will distil the lessons learned from the international literature on stroke systems of care and examine their applicability in the Chinese health systems context. Second, fieldwork involving data collection with older adults, lay caregivers, and professional health and social care providers will be conducted in an urban and a rural prefecture of Guangdong Province, (Guangzhou and Meizhou respectively) to document experiences, patterns of care-seeking, and perceived needs for chronic disease management. A specific focus on stroke patients' journeys through recovery and rehabilitation will allow us to identify the systems elements, relationships, and processes that hinder or enable integrated care. Third, we will synthesize the data collected in order to model the current landscape and dynamics of health and social care systems' responses to stroke among older adults. Finally, a participatory workshop with key health and social care stakeholders will generate concrete recommendations regarding potential interventions that can integrate elements of current health and social care systems to improve person-centred management of stroke survivors. This work creates a timely collaborative and interdisciplinary platform for development of a larger proposal that can implement and evaluate one or more of the one or more of the strategies identified to support development of a stroke care system in China.

In China, the annual stroke mortality rate has exceeded heart disease to become the leading cause of death and adult disability (approximately 157 per 100 000). Stroke prevention, control, treatment and management have received increasing priority in China. However, stroke care still faces great challenges with a non-systematic and patchy approach to stroke prevention and control, and lack of skilled and trained personnel treating and managing stroke. Our project is timely, supporting the national declaration to fight stroke in 2012, and well-placed to make a strong empirical contribution to ongoing efforts to build evidence for a stroke system of care in the country.

In the short term, this study will create a platform for development of a larger proposal that can implement and evaluate strategies to integrate health and social care for optimal recovery and rehabilitation of stroke patients. Beyond impact on academic scholarship (see 'Academic Beneficiaries'), the project will have an impact on the capacity of Chinese researchers to develop proposals and engage in international collaboration in social science research as applied to health systems. It will also stimulate dialogue between health and social care providers, and foster greater public awareness of the implications of fragmented care for the health and well-being of elders, and support of older adults' entitlement to care. The tools developed and piloted for the fieldwork, for example, the short documentary film, vignettes, and patient journey assessment records can have a direct impact on practice in chronic disease management.

In the long term, the study will contribute to mobilising wider social support, resources, and political will for implementation of a stroke care system that can potentially impact the management of the 300,000 stroke patients in Guangdong and nearly 8 million stroke survivors in China.