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

Lead Research Organisation: Queen Margaret University Edinburgh
Department Name: Institute for Global Health & Developmnt

Abstract

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.

Technical Summary

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.

Planned Impact

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.

Publications

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Title Short film entitled Chinese Grandmothers 
Description Based on the data collected from older adults in Guangdong province, one of our collaborators produced a 20-minute film that explores the lives of four women and their notions of health and aging, relationships with their families, living with chronic conditions, and health-care seeking. Laura Tan, a visual ethnographer based at Sun Yat Sen University, worked with us during the field data collection activities, and focused the film on four of the women she met in the course of the study. The short (22 minutes) documentary was shown by a on a well-known online Chinese news channel during the Chinese Spring Festival - see link below. 
Type Of Art Performance (Music, Dance, Drama, etc) 
Year Produced 2018 
Impact The launch of the film has just happened, and we have yet to hear of its impact. We hope to work on editing the film a little more for English-speaking audiences. 
URL http://www.thepaper.cn/newsDetail_forward_1998543
 
Description In Guangdong Province, China, the growing burden of illness for older people and their families has put great pressure on the health system. Health and social care services and resources for older adults are limited in number and scope and fragmented. The emerging topical interest in 'integrated care' in the health system has is predominantly focused on elder care, as the conventional family-based care model is being is being challenged by internal migration trends and the legacy of the 'one-child' family planning policy. Several recent policies to facilitate the integration of health and care services for older people have led to experimental models, for example, providing medical services within social welfare institutes, or including elderly/social care functions for older people within medical institutions. Collaboration, in terms of referral and joint working is being explored between the social welfare institutes (including community-based care organisations) and health services at different levels. Private enterprises and companies are also investing in developing integrated institutions as part of the 'elder care industry'. A number of challenges arise in this landscape of emerging integrated 'elder care': 1) there is a lack of professional guidance for how best to implement integrated care; 2) principles and experiences of integrated care for older adults in high income countries may not be readily applicable to the Chinese context. With respect to integrated care for stroke rehabilitation, we note that there are several regional disparities in medical insurance, severity of patients' conditions pre-hospital delays, length of hospital stay and hospitalization costs which influence the scope of care provided. Hospitals are limited in their capacity to deliver comprehensive and integrated stroke care as expertise and knowledge regarding stroke and stroke care is lacking among both providers and patients; there is inadequate coordination of the stroke team and inconsistency in care following discharge of stroke patients. Finally, stroke patients have insufficient financial protection, resulting in considerable economic hardship and a greater burden of rehabilitation support and care placed on the families of stroke patients. The concept and practice of 'integrated care' for older adults suffering from stroke and other chronic disease events in this setting must be adapted to culturally different concepts and expectations around aging and health as well as systems that differ in structure, organisation, philosophy, and remuneration of care services.
Exploitation Route This was an ambitious exploratory grant (Foundation Award) that sought to triangulate data sources from older adults, health and social care providers, and hospital records on the experience of older adults recovering from stroke and other non-communicable, chronic disease events. Pending a series of research publications that are still under preparation, and discussion with partners, the data collected might be used to support a larger grant exploring the viability, costs, and impact of more recent emergent models of integrated health and social care for older adults in China.
Sectors Healthcare,Other

 
Description A short film was produced based on interviews and ethnographic film with older women in Guangdong Province to highlight issues of aging and the experience of chronic disease. Please see description below: Chinese Grandmothers The 'Chinese Grandmothers' film follows 4 elderly Chinese women and depicts their life histories, daily lives, and chronic care experiences in urban areas of two cities in Guangdong Province, China. The film mirrors the dynamic responses of the older people in the context of population aging and urbanisation in China. This film is part of a collaborative project between Dr Karina Kielmann, Prof Brendan McCormack and PhD candidate Guangyang Zou of Queen Margaret University and Sun Yat-Sen University in Guangzhou, China. This project, titled 'Whole systems care for post-stroke management in older adults: exploring the options for integration of health and social care in China' is supported by the Joint Health Systems Research Initiative(2016-2018). Watch the film on 'The Paper' website (22 mins): http://www.thepaper.cn/newsDetail_forward_1998543
First Year Of Impact 2018
Sector Culture, Heritage, Museums and Collections
Impact Types Cultural

 
Description Dissemination event (university) 
Form Of Engagement Activity Participation in an open day or visit at my research institution
Part Of Official Scheme? No
Geographic Reach Local
Primary Audience Postgraduate students
Results and Impact 30 university staff and students (post-graduate and post-doctoral) attended a Chinese New Year's event where three members of the research team (Kielmann, Zou, McCormack) gave short presentations, showed the film that had been produced, and set up visual poster displays from preliminary data analysis of the work. This was an informal event with Chinese refreshments and tea which was much appreciated. It generated great discussion on the issue of health and social care for older adults in China, and provided the team with an opportunity to interact with other departments (Nursing and Person-centred Practice) which we hope will lead to future collaboration.
Year(s) Of Engagement Activity 2018
 
Description Stakeholder meeting with local Health Bureau officials (Guangzhou, China) 
Form Of Engagement Activity Participation in an activity, workshop or similar
Part Of Official Scheme? No
Geographic Reach Regional
Primary Audience Professional Practitioners
Results and Impact Approximately 20 Health Bureau officials and representatives from social care organisations were invited to a stakeholder meeting at Sun-Yat-Sen University in order to hear about the project aims, scope, and activities over the next year. They were invited to discuss the project openly in terms of the impact on local elder care activities and plans in the province.
Year(s) Of Engagement Activity 2016