"Combination of medical care and support" refers to a new model of elderly care service that places more importance on health and medical services for the elderly, combines nursing centers and geriatric hospitals, and combines life care and rehabilitation care.It includes traditional life nursing services, mental and psychological services, elderly cultural services, and more importantly, medical rehabilitation and health care services, including medical services, health consultation services, health examination services, disease diagnosis and treatment and nursing services, serious illness rehabilitation services and hospice care services;

      In the 2020 Work Plan for Promoting and Implementing healthy China Action released by the Office of healthy China Action Promotion Committee, among the key tasks of each special action,It involves action to popularize health knowledge, action to promote rational diet, action to promote national fitness, action to promote mental health, action to promote healthy environment, action to promote maternal and child health, action to promote health in primary and secondary schools, action to promote occupational health, action to promote health in the elderly, etc., many of which are related to general health;

1. "Institutional pension" combined medical and elderly care model

    （1）"Large pension + small medical care" type:

    The model is to build small medical institutions and add medical services on the basis of old-age care institutions, with old-age care as the main and medical care as the auxiliary;

      At present, most pension institutions adopt this mode to carry out the combination of medical and nursing services.This model has obvious disadvantages: internal medical institutions can only carry out outpatient service, can not solve the problem of direct hospitalization in pension institutions;At the same time, the operating cost of medical institutions is high, and the salary of medical staff alone brings a great burden to pension institutions, which are difficult to support in the long term;

     Survey found that many elderly care institutions have applied for internal medical institutions, medical institutions can not adhere to the trial operation for a period of time and "people leave the building empty";

      (2) "medical care, pension" type:

      Emphasis should be placed on the development of both medical and nursing care.New large pension institutions, simultaneous construction of supporting general hospitals or nursing homes, to achieve equal development of medical care and pension;Some medical institutions with idle resources have turned their surplus resources into elderly care services by opening special care wards for the elderly or directly transforming into nursing homes and rehabilitation centers to provide combined medical and nursing services;

     Results show that the mode integrates medical and old-age care resources, forms an operation situation of promoting nursing through medical care and supporting medical care, and can basically realize the sharing of medical care for the elderly without critical illness in the institution;

     (3) "big medical + small pension" type:

     In most cases, large medical institutions build small pension institutions. By equipping relevant facilities and increasing nursing staff, a professional pension institution under the hospital is built inside the medical institutions;

     Research found that this model is the use of high-end medical resources to set up pension institutions, advantages of pension, health care, environmental conditions more high-end, but there are obvious disadvantages: on the one hand, the existing hospital economy even waste of resource utilization, on the other hand is pension cost is higher, economic condition of the lowest average families;

    （4）"Big medical treatment + small rehabilitation" type:

     In most cases, large-scale medical institutions build small rehabilitation institutions, such as geriatric departments, rehabilitation departments and rehabilitation centers, with medical treatment as the main and rehabilitation as the auxiliary. In most cases, rehabilitation and maintenance functions are added to the original medical institutions to build a service system connecting medical treatment, care and rehabilitation.

     It is found that most of these models develop well, but the proportion of "nursing" is small in the system of "medical, health and nursing integration";

     （5）"Two houses in one" type:

      In most cases, the nursing homes built by local governments are managed and operated by local township health centers. Township health centers and nursing homes realize "integration", or township health centers directly build nursing homes to realize the combination of medical care.Township health centers use the resources of nursing homes to take good care of the "five guarantees for the elderly", but also accept part of the social elderly.This model is an effective integration of the existing pension and medical resources, which can activate the supply gravity of medical and nursing resources, serve the elderly in rural areas nearby, and help them realize local pension;

     The results show that compared with "public construction and private" pension services, this model is easier to maintain and increase the value of the original state-owned assets of nursing homes, and is an ideal combination of medical care model;

      (6) "integration of health care" type:

      On the basis of hospitals, new nursing homes and nursing homes will be built to implement integrated operation of medical, health and nursing.The advantage of this model is that after a period of hospitalization, the physical condition of rehabilitation patients greatly improved, many patients from bedridden to independent walking, excellent social benefits;During the period of hospitalization, the rehabilitation patients receive not only rehabilitation treatment services, but also old-age care services. After rehabilitation and discharge, there may be a group of people living in old-age care institutions for a long time. The economic benefits of institutions will be greatly improved, which is the combination mode of medical and old-age care with the highest efficiency of resource allocation;

     （7）"Individual clinic + small pension" type:

     This model is generally held by individual clinics. The front hall is a clinic, and the back is a small family-style pension. Doctors and nurses in the clinic provide medical services for the elderly, and another 1-2 nursing staff are employed to take care of the elderly;

     The research found that the advantages of this model are low fees, close to home, relatively convenient, full use of resources, good effect;The disadvantages, however, are relatively simple medical and nursing facilities, substandard care and diseconomies of scale;

     （8）"Pension institution + overall medical service outsourcing" type:

      This model refers to do not have the conditions for establishment of medical institution endowment institutions, medical institutions and the nearest hospital function (more for medical institutions (mostly level general hospitals) signed a cooperation agreement, the overall medical service outsourcing for pension institution for medical institutions, pension institutions provide places for medical institutions and necessary condition,Medical institutions set up branches such as branches in pension institutions, and medical institutions send medical staff to the pension institutions to provide them with overall medical outsourcing services, or "overall trusteeship of medical services in pension institutions".The advantage of this model is that the responsibilities, rights and benefits of medical and nursing care parties are clear, and both parties use the market mechanism to carry out cooperation;

     Research found that this was the medical specialized division of labor and cooperation, improve the efficiency of resource utilization effective forms, especially suitable for 100-300 people of endowment institutions to carry out medical keep combining services (smaller pension organizations using this model, medical institutions may cause service unsustainable, "money" to pension institutions for medical institutions offer certain subsidy);

     (9) "Pension institution + Medical service Green channel" type:

     This mode refers to the pension institutions and adjacent medical institutions signed a cooperation agreement, medical institutions for the pension institution patients to provide "green channel", priority to provide hospitalization, remote consultation, appointment registration and other services, this is my province at present to carry out the most medical care combined with a model.The disadvantages of this mode are as follows: the cooperation between medical institutions and pension institutions is based on trust and interest driven by both sides, and the cooperation between the two sides lacks effective restraint and interest coordination mechanism. Once the agreement affects the interests of one party, it is easy to terminate the agreement, and it is difficult to ensure the effectiveness and continuity of the cooperation;

     Research found that this model is difficult to realize the medical integration, basically belongs to the "form", it is difficult to carry out substantive cooperation between medical pet, is basically each dry (such as pension institutions need to be hospitalized patients, although the agreement calls for priority to cooperative medical institution in the hospital, but the patient's family does not necessarily agree with, to the larger, more likely to be a trust of hospital), over time,Difficult to long-term cooperation;

     (10) "large pension + small medical care + medical service green channel" type:

     In this mode, pension institutions themselves first build a small medical institution, such as a clinic or clinic, and at the same time sign cooperation agreements with other large-scale medical institutions, which provide "green passage" for the patients of pension institutions to seek medical treatment.For general medical problems, the nursing home will solve them on its own. When a serious patient is immediately transferred to a cooperative medical institution for diagnosis and treatment;

     Of the above ten "institutional endowment" service modes, the first seven are "integrated" mode, the eighth and ninth are "embedded" mode, and the tenth is "hybrid" mode.The first eight are closely combined with medical care, the ninth is loose combination of medical care, the tenth is half loose and half tight.

      At present, when the relevant departments introduce the results of the coverage rate of the combination of medical and nursing care, they tend to sign agreements in a loose mode;

     According to the survey, we believe that the loose mode basically belongs to the "mode of doing business", and it is difficult for medical institutions and pension institutions to cooperate substantively and operate in market.The combination of medical care must use the "integration" development model;

2. Main modes of the combination of medical and nursing care in "Community Endowment" :

     (11) "Community health Service institution + day Care Center for the elderly" type:

     The facilities of day care centres can be shared in many aspects, such as elderly care, medical care and basic public health services, with efficient allocation of resources;Generally, most of the people sent to "day care centers for the elderly" are "one body with multiple diseases", and these people need more medical staff to provide services, so this model can better meet the medical needs of the elderly;At the same time, only when medical personnel undertake corresponding services, can the children of the elderly be more assured and can send the elderly to day care centers more;

     Research found that community health service institutions belong to the substantive institution, by operating the old day care centers, in line with the "responsible, accountable" requirement, and separate ownership and management, is solved by community residents' committees for the elderly day care center management unsuitable system, unclear ownership of the problems of operating,It also solved the problem of idle assets of day care centers for the elderly, and resolved the shortage of housing for community health service institutions, realizing resource sharing；

     It can not only reap the social benefits of "better guarantee the health care of the elderly and make the elderly children feel at ease", but also bring due economic benefits to the community health service institutions through more services. At the same time, it can also promote the industrialization of the elderly, and truly achieve a win-win situation, which is the ideal way to realize the combination of medical care at the community level;

     （12）Co-construction and Sharing of Community Medical and Nursing Facilities:

     The elderly service facilities will be planned and built in a unified manner with community-level medical and health service institutions, such as happiness centers and clinics in rural areas, and community day care centers and community health service institutions in urban areas.Through simultaneous construction, the combination of medical care and nursing care at the community level can be realized in one step;

     (13) "Professional pension operation institution + day Care center for the elderly" type;

      Day care centers for the elderly are managed by large professional pension institutions, and the idle resources of day care centers for the elderly are fully utilized.The survey found that this model was difficult to achieve scale efficiency due to the small scale of day care centers for the elderly (usually only 10 beds).At the same time, some professional elderly care institutions cannot provide adequate medical services, making it difficult to combine high-quality medical care with elderly care. Once government subsidies are reduced or removed, it will be difficult to maintain them；

     （14）Model of "agreement between community comprehensive elderly care service institutions and community health service institutions" usually means that the community builds comprehensive elderly care service centers and signs cooperation agreements with community health service institutions in order to carry out the combination of medical care and elderly care. However, the services are mainly basic public health services, with relatively few basic medical services；

    （15）"Village health room + rural happiness hospital" type：

     Rural happiness centers are managed and operated by village clinics to realize the combination of medical care and nursing in rural communities, but there are few typical cases at present；

3. Main modes of "Home care" combining medical care:

     (16) "Internet + wearable device + physical service organization" type：

     This mode requires that the elderly at home be equipped with wearable devices to remotely monitor their life and physical conditions. Through information management platforms and the use of the Internet and the Internet of things,Relevant data on the daily life, health and travel of the elderly should be timely transmitted to solid medical and nursing care institutions or solid community institutions (such as nursing stations, community health service institutions) and their children；

     Substantive service institutions make service plans based on the physical monitoring data of the elderly, and timely provide the elderly at home with related services such as diet, daily living, medical care, fire protection and security, leisure and entertainment, and alarm and call for help according to the needs of the elderly and their children；

     The survey found that, at present, many enterprises are keen to develop this model, some design scale is large, but there are few successful cases;

     (17) "home care + family doctor contract service" type：

     Signing this pattern was conducted by the family doctor service activities, promote the family doctor service, with the needs of the elderly residents to sign the service agreement, contractual services, signing can get family doctors to provide health care counseling, high-quality medical services, precise appointment referral service, health guidance, disease intervention, domestic sickbed, health management service,The elderly can enjoy medical services provided by quality medical resources, basic public health services and personalized health management services at home；

     According to the survey, this model mainly solves the medical service problem of the elderly at home, but the socialized life service can not be effectively solved. We believe that this model is not a substantive combination of medical care and nursing, and still belongs to the basic public health service；

    （18）"Home care" service in home care + Long-term care Insurance "type:

     This model provides home-based care services for eligible disabled elderly people, who are cared for at home by their family members at ordinary times. Designated medical institutions of long-term care insurance provide "home care" services focusing on rehabilitation, and relevant expenses are mainly provided by medical insurance funds；

     At present, this home-based care mode is mainly aimed at urban workers enjoying long-term care insurance. Although it is popular among residents, it has high social cost, and the time cost between medical personnel and residents' homes is also high. Compared with the "in-home care" of disabled elderly people in pension institutions, the resource allocation efficiency is not good；

     In addition, the survey also found that some large institutions that combine medical care with elderly care provide extended services to community elderly care and home elderly care while doing a good job in institutional elderly care, and simultaneously carry out the combination of medical care with elderly care at the three levels of institutional elderly care, community elderly care and home elderly care.It has formed an "intelligent model of integrated development at the three levels of institution, community and home", combining medical care with good economic and social benefits；

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