Special Issue:Contracted family doctor services
For building a healthy China, it is essential to expand the coverage of family doctor services. In young and middle-aged office building occupants, the rate of contracting family doctor services is low. Shanghai has taken the lead in exploring building-based family doctor services, and providing on-demand health management services. So it is particularly meaningful to study the health needs in young and middle-aged office building occupants.
To investigate the needs and associated factors of contracted family doctor services among young and middle-aged office building occupants in Shanghai.
A questionnaire survey was conducted from December 2019 to December 2020 with a cluster random sample of young and middle-aged office building occupants (aged 18-59 years) selected from representative office buildings in Shanghai's Hongkou District, Pudong New District, and Jing'an District of Shanghai for understanding their sociodemographic characteristics, health and healthcare-seeking conditions, knowledge of family doctor services, and needs of essential and personalized family doctor services. Multiple Logistic regression analysis was used to analyze the factors affecting the needs of family doctor services.
In all, 2 366 cases attended the survey, and 2 272 of them (96.03%) who completed the survey effectively were included for analysis. Among them, 87.65% (1 874/2 138) had general, moderate or strong needs for essential family doctor services, and 70.59% (1 452/2 057) had needs for personalized family doctor services. Multiple Logistic regression analysis indicated that age, education level, self-assessed social class, understanding of one's own health, self-assessed health status, chronic disease prevalence, mental health status, preferred healthcare setting for treating common diseases, treatment experience in a community health institution, understanding of and degree of trust in a family doctor, and understanding of building-based family doctor services and the specific scope of the services were associated with the needs of essential family doctor services (P<0.05). Education level, social health insurance, commonly used drugs, chronic disease prevalence, preferred healthcare setting for treating common diseases, treatment experience in a community health institution, understanding of building-based family doctor services, and understanding of the scope of building-based family doctor services were associated with the needs of personalized family doctor services (P<0.05) .
The contracted family doctor services were in high demand in young and middle-aged office building occupants. Improving health literacy in this population, modifying publicity strategies regarding the services, and improving the capabilities of the family doctor team and primary medical institutions, may be conducive to increasing the rate of contracting family doctor services in this group.
Shanghai is gradually expanding the supply of family doctor contract service to building functional communities, but the prevalence of met needs of such services in young and middle-aged office building occupants is still unknown, and relevant studies on the prevalence and associated factors could inform the development and improvement of policies regarding building-based family doctor services.
To explore the prevalence of met needs for contracted family doctor services and associated factors in young and middle-aged office building occupants.
A questionnaire survey was implemented from December 2019 to December 2020 in the setting of office buildings selected by typical sampling from Hongkou District, Pudong New District and Jing'an District of Shanghai. Among the young and middle-aged occupants (n=2 272, 18-59 years old) selected from the buildings by use of cluster random sampling to attend the survey, 1 137 with an experience of using contracted family doctor services were determined as the participants. The survey involved four aspects, including sociodemographic and economic characteristics, health status, understanding level of contracted family doctor services, and met needs of these services (containing essential and personalized service needs assessed using a 5-point Likert scale). Multinomial and ordinal Logistic regression was used to analyze factors associated with met needs of contracted family doctor services.
The prevalence of having needs of essential family doctor services considerably/completely met was 39.61% (425/1 073). And that of having needs of personalized family doctor services considerably/completely met was 39.01% (419/1 074). Multinomial and ordinal Logistic regression analysis revealed that registered place of household (Shanghai or not), occupation, annual income, self-rated health, understanding of the "1+1+1" type of contracted family doctor services, level of trust in family doctors, and evaluation of family doctors' service capabilities were associated with met needs of essential family doctor services (P<0.05). Sex, annual income, chronic disease prevalence, understanding of the "1+1+1" type of contracted family doctor services and the composition of a family doctor team, as well as evaluation of family doctors' service capabilities were associated with met needs of personalized family doctor services (P<0.05) .
The prevalence of self-reported met needs of essential or personalized family doctor services in the young and middle-aged office building occupants was about 40%, which was associated with sociodemographic and economic characteristics, health status, understanding level of contracted family doctor services, and self-assessed family doctors' service capabilities. It is recommended to improve the publicity of the system of contracting family doctor services, customize personalized service plans according to the characteristics and differentiated needs of the population, improve the family doctor's service capabilities and enrich the services.
The competencies of general practitioners (GPs) have become a basis for promoting the implementation of tiered diagnosis and treatment, and effective supply of primary healthcare services against the backdrop of the initiation and implementation of contracted services provided by GPs in primary care in China. The regular competency-based assessment systems with clear objectives and strong operability can positively stimulate GPs to provide contracted services with higher quality and efficiency.
To develop a competency rating scale for GPs, providing a tool applicable to scientific evaluation of GPs' competencies in China.
By use of a GP competency model, and review results of relevant studies and competency scales, the measurement items and the draft of the scale were developed, then were revised according to the results of a questionnaire survey conducted with GPs in primary care in major provincial administrative regions from April to August 2021. Among the 402 responders, the answers of 201 cases (sample A) were used for exploratory factor analysis, and those of the other 210 cases (sample B) were used for confirmatory factor analysis. Based on this, the reliability and validity of the final scale were tested.
The final General Practitioner Competency Rating Scale includes four dimensions (general service competency, humanistic competency during practice, teamwork and cooperation competency, learning and development competency) and 21 items. The Cronbach's α for the scale, and the afore-mentioned four dimensions was 0.929, 0.877, 0.850, 0.812, and 0.811, respectively. The P-value of Bartlett's test of sphericity was less than 0.001 (approximate χ2=2 319.759, P<0.001) , reaching a significant standard, and the KMO value (0.923) was close to 1.0. By exploratory factor analysis, four common factors were extracted, explaining 67.680% of the total variance. The first-order confirmatory factor analysis showed that the correlation coefficients of the four dimensions were between 0.68 and 0.72, and highly correlated. The second-order confirmatory factor analysis results were: χ2/df=1.312, RMSEA=0.039, CFI=0.976, GFI=0.913, NFI=0.907.
Our scale has proven to have good reliability and validity, which may be used for assessing the competencies of GPs delivering contracted services in China.
Recent Advances in Assessment Tools for Family Doctor Teams
With the advancement and development of the family doctor system, family doctor teams have become a main provider of primary health services, which has raised new requirements for the evaluation of their services. We comprehensively reviewed recent developments in evaluation tools for family doctor teams: examples from the UK, the US, European countries, Australia and Canada have shown that traditional evaluation tools based on the structure-process-outcome model are being replaced by some models that focus more on the team's organizational environment, internal relationships, psychological state and continuous improvement. In China, the development of assessment tools for family doctor teams has been initiated recently, with major manifestations of various research approaches but lack of high-quality theoretical models, and high-quality reliability and validity tests. Moreover, the assessment tools are lack of diverse domains, and indicators for assessing team relationships, emotions and psychology as well as continuous improvement. On the basis of international experience, we recommend using the input-mediator-output-input model as a theoretical basis to develop highly applicable tools for assessing family doctor services in China.
The prevalence of sub-health problems is increasing in young and middle-aged office building occupants, in which the percentage of mental health problems is on the rise. Shanghai took the lead in delivering family doctor services via the health station set in an office building in June 2018, but mental health in young and middle-aged people has not yet been insufficiently covered by the services.
To assess the prevalence of anxiety and influencing factors in young and middle-aged office building occupants in Shanghai.
A questionnaire survey for estimating anxiety prevalence was carried out in typically sampled office buildings from Hongkou District, Pudong New District and Jing'an District of Shanghai during December 2019 to December 2020. Cluster random sampling was used to sample young and middle-aged occupants (18-59 years old) in the buildings, and 2 198 cases of them who completed the survey were included as the participants for analysis. Anxiety was diagnosed by the score of the Zung's Self-Rating Anxiety Scale. Multiple linear regression was used to estimate the association of anxiety prevalence with socio-demographic and economic characteristics, and health status as well as lifestyle.
Among the participants, the prevalence of no anxiety, mild, moderate and severe anxiety was 60.42% (1 328/2 198), 18.61% (409/2 198), 12.46% (274/2 198), and 8.51% (187/2 198), respectively. Multiple linear regression analysis found that registered place of household (Shanghai or not), education level, self-rated social class, self-rated health, frequency of physical examination, level of fatigue, chronic disease prevalence and regular medication were associated with anxiety prevalence (P<0.05) .
The prevalence of anxiety was high in this group of population, which may be associated with the population characteristics. In view of this, mental health should be valued during the delivery of family doctor services for these people, and targeted interventions can be provided according to personal anxiety status when necessary.
Barriers and Improving Paths to the Implementation of Contracted Family Doctor Services in China：an Analysis Using Smith's Policy Implementation Process Model
The contracted family doctor services (CFDSs) is a key action selected to be implemented to deepen the reform of the pharmaceutical and healthcare system, enrich primary care services, and achieve the strategic goals of health China. Moreover, the implementation of CFDSs is a main approach to better safeguarding people's health. To effectively promote the development of CFDSs, China has successively launched various relevant supportive policies, and the local governments have been actively exploring practicing approaches. So far, remarkable results have been achieved nationwide, yet there are still many challenges, among which implementation difficulty is a major factor influencing further promotion of CFDSs. We analyzed the implementation process of CFDSs using Smith's policy implementation process model, and identified many barriers to the implementation of CFDSs, such as lack of rule of law, low level of policy executors, insufficient incentives, and impact of policy environment. In view of this, we put forward the following recommendations on exploring innovative policies for sustainable development of CFDSs: designing top-level policy objectives for CFDSs development from perspectives of law and system, improving qualities and professional identity of providers of CFDSs, establishing mutual trust between doctors and patients, and optimizing the policy implementation environment.
In China, team-based service delivery model is a major emerging model for contracted family doctor services, but there is a lack of a tool for assessing the overall effectiveness of the family doctorteam.
To develop a IMOI model-based system for assessing the effectiveness of family doctor teams in Beijing, aiming at proving a tool for guiding the improvement and continuous development of the family doctor team.
The first draft of the Family Doctor Team Effectiveness Evaluation System (FDTEES) was developed using literature review and personal interview. Then the indicators of the system were assessed and revised according to consensuses of our analysis and the results of two rounds of consultations carried out between May and July 2021 using the Delphi technique (one was conducted with 24 experts, and the other with 21 experts) . The weight of the indicators of the system was determined by and analytic network process.
The response rate of experts in the first, and second round of consultation was 87.5% (21/24) , and 100.0% (21/21) , respectively. The authority coefficients for the consultations ranged from 0.88 to 0.91. Kendall's W for the importance and applicability of the indicators of the FDTEES was 0.138 (P<0.001) , and 0.263 (P<0.001) , respectively, in the first round of consultation, was 0.255 (P<0.001) , and 0.257 (P<0.001) , respectively, in the second round of consultation. The final FDTEES consists of 71 indicators, including 7 first-level indicators〔team building (0.155) , quality of team members (0.155) , team member relationship (0.097) , team process (0.141) , team service results (0.155) , perception and satisfaction (0.155) , team redevelopment (0.141) 〕, 16 second-level indicators, and 48 third-level indicators.
The IMOI model-based FDTEES developed by us assesses the effectiveness of family doctor teams in Beijing from a team perspective, which may be a reference for effectiveness evaluation and development of family doctor teams in Beijing.
There is an issue of mismatch between supply and demand of medical care resources in China. The implementation of contracted family doctor services is an effective measure to address the issue, and to improve the hierarchical diagnosis and treatment system. Therefore, it is urgent to speed up the training and ensure the training quality of general practice workforce.
To develop a comprehensive and systematic general practitioner (GP) competency model after analyzing the concept and structural domains of competencies (including inner competencies) required for GPs to deliver contracted healthcare services, providing insights into the realization of training eligible GPs in terms of quantity and quality, and the improvement of quality and efficiency of contracted services.
From December 2020 to September 2021, we conducted in-depth, semi-structured interviews with 38 GPs from 10 medical institutions in four cities (Zhenjiang, Taizhou and Suzhou in Jiangsu Province, and Foshan in Guangdong Province) , then treated the interview results applying the three-level coding and theoretical saturation used in the grounded theory. After that, we developed a General Practitioner Competency Model.
The model consists of 10 items, which belong to four domains: general care capability, humanistic practice capability, team cooperation capability, learning and development capability. General care capability and learning and development capability belong to external competencies, which represent the external performance and driving force of competencies, and determine the level of competencies of GPs to provide contracted services. Humanistic practice capability and team cooperation capability reflect the internal traits and competencies, which belong to the inner competencies, and determine the potential of GPs to provide contracted services.
The model developed by us is complete and comprehensive, in which the inner competencies of GPs have been fully explored, which may be contributive to the training of GPs delivering contracted services, and to the development of a GP competency assessment system using quantitative empirical methods.
Since the full implementation of contracted family doctor services in 2016, we have achieved phased results. Further work needs to be paid equal attention to "quality" and "quantity", focusing on improving the residents' sense of service access and satisfaction, however, at present, the residents' evaluation of contracted family doctor services is not clear.
To investigate the contracted residents' evaluation for the continuity of family doctor contract, explore its influencing factors, and propose improvement strategies.
This study used a multi-stage stratified random sampling method to select 1 193 contracted residents from 9 community health service institutions and 9 township health centers in Heze City, Shandong Province in January 2021. A household survey was conducted on the included residents by using the continuity dimension of the Chinese version of the Primary Care Assessment Tools (PCAT) , which contains 15 items. We compared the PCAT-continuity dimension scores of contracted residents with different characteristics, and used multiple linear regression to analyze the factors influencing the PCAT-continuity dimension scores of contracted residents.
A total of 1 098 valid questionnaires were collected, with a valid response rate of 92.04%. 541 (49.27%) of them were contracted to community health service institutions and 557 (50.73%) of them were contracted to township health centers. The average score of the PCAT-continuity dimension of the contracted residents was (3.38±0.51) . The item with the highest score was "Does your family doctor listen to you patiently", with a score of (3.64±0.59) . The item with the lowest score was "Would you be willing to change your family doctor if it was easy to do so", with a score of (2.98±0.92) . Multiple linear regression analysis showed that the type of contract organization, age, education, marital status, occupation, and chronic diseases were the factors that influence the PCAT-continuity dimension score of contracted residents (P<0.05) .
The contracted residents had an overall good evaluation on the continuity of contracted family doctor services, and the long and stable doctor-patient relationship had been established. Township health centers are better than community health service institutions. To further improve the contracted residents' evaluation of contracted family doctor services, we need to pay more attention to the type of contracting institution, the age, education level, marital status, occupation of contracted residents and their chronic diseases.
With the continuous progress of the New Medical Reform, contracting service by family physicians has increasingly become an important guarantee for the basic medical care and health of the people, and the agreements of family doctors' contracting service has become the premise of achieving "everyone has a family doctor". However, the standardization and binding force of the agreement still remain to be studied.
By analyzing the agreements of family doctors' contracting services, we expected to further standardize the contracting services and improve the standardized management level of the services contracted by family doctors.
According to the purpose of the survey, the contracting agreements of the 14 community health service centers were finally selected as subjects by random sampling among 1-3 community health service centers in each of the nine main districts of Chongqing in July 2021. The main analysis framework was based on the contracting subject, contracted service, contracting fee mechanism, and the rights and obligations of the contracting subject. Finally, descriptive analysis of the agreements was performed by means of content analysis.
When compared the agreements in different districts, the contents of basic medical services and basic public health services were relatively similar (basic medical services included diagnosis and treatment services for common diseases, frequently occurring diseases and traditional Chinese medicine, etc., and basic public health services included establishing resident health files, providing health consultation, and vaccination, etc.) . There were differences in the terms of years of service, personalized services, etc. among family doctors in different regions of Chongqing: there were 12 agreements that specified a binding period of 1 year, 1 agreement whose duration was decided by the parties, and 1 agreement that did not specify the binding period. Among all agreements, the definition of the rights and obligations of contracting subjects and parties was vague. Among them, contracting subjects of 6 agreements included community health service centers, superior guidance hospitals, family doctors and representatives of heads of households or family representatives, 6 agreements included community health service centers, family doctors and representatives of heads of households or family representatives, 1 agreement included community health service centers and household heads, and 1 agreement did not specify the contracting subject.
It is necessary to further clarify the objects and agreements of contracting service, and improve the rights and obligations of the contracting subjects in Chongqing. Combined the experience of implementation of contracting services by family doctors of various regions, it is necessary to improve the performance effectiveness and the quality of the contracted services, and promote the implementation and development of the family doctors' contracting services.
Constructing Assessment Indicators Regarding Effectiveness of a Family Doctor Team Using the IMOI Framework：a Systematic Review
Improving the effectiveness of a family doctor team, the main provider of primary healthcare, is an important means to enhance the effectiveness of community health services. The evaluation of team effectiveness has gained increasing attention.
To classify and summarize the assessment indicators and analyze the core dimensions of each indicator set regarding the effectiveness of a family doctor team using the input-mediator-output-input (IMOI) framework.
Studies about the development of indictors for assessing the effectiveness of a family doctor team were systematically retrieved from databases of PubMed, CNKI, Wanfang Data and VIP from January 2000 to October 2020. Indicator mapping was used to classify and compare the indictors according to the structure of IMOI framework.
Fourteen studies were included, 4 of which were published abroad, and 10 in China. The indicators were classified using the IMOI framework: organizational environment, team building, and team member quality were classified as input (I) , team emergent state and team process were classified as mediator (M) ; service achievement and personal feedback were classified as output (O) , but no indicators were classified as input (I') .
The qualities of theoretical models and research methods used for developing assessment indicators regarding the effectiveness of a family doctor team need to be improved. The assessment system developed based on the IMOI framework may be a good tool for evaluating team effectiveness, but the indicators need to be supplemented further.
Population aging is getting worse in our country. Family doctor contract service plays an important role in boosting the construction of hierarchical diagnosis and treatment system and establishing a reasonable and orderly medical order. Current research about family doctor contract service policy mainly focus on qualitative evaluation, and there are few researchers use tools to quantitatively evaluate each individual representative policy.
This study aims to quantitatively evaluate the pros and cons of six Chinese central government policies about family doctor contract service, thus, proposing strategies and measures to promote the high-quality development of our country's family doctor contract service, and helping the construction of healthy China.
We searched Peking University's PKULAW.com and websites of some relevant ministries of the State Council of China from January 1, 2015 to April 30, 2022. The key word was "family doctor". The software ROSTCM 6.0 was used for text mining. Based on the results, this study selected central government policies about family doctor contract services, then used the PMC index model to quantitatively evaluate these policies.
This study included thirty-two policies based on inclusion and exclusion criteria. The top five high-frequency keywords in the field of family doctor services are "contract service" (n=274) , "health" (n=272) , "medical" (n=264) , "family doctor" (n=225) , and "contract" (n=180) . They were marked as P1-P6, respectively. In terms of methods and other aspects, the scores of each dimension are relatively high. The results of quantitative evaluation showed that the ranking of policies is P1>P3>P2>P6>P4>P5. Three policies were rated as excellent, the other three were rated as acceptable. The scores were relatively high in the policy content, policy nature, policy evaluation, policy field and policy role.
Our country's family doctor contract service policy had a relatively broad content and is relatively mature. It is suggested to pay attention to the combination of long-term, medium-term and short-term validity of the policies, improve incentive approaches from multiple perspectives, enhance the sense of professional honor of family doctors, and use a variety of policy tools and policy action.
It is urgent to improve the effectiveness of contracted family doctor services due to high prevalence of problems such as uninformed contracting, and contracting but making no appointments.
To analyze the mechanism influencing the effectiveness of contracted family doctor services.
From September 2021 to January 2022, in-depth interviews were conducted with 24 family doctors, 8 institutional managers, and 25 contracted residents purposively sampled from Weifang, Heze, and Jinan of Shandong Province, using an interview guide regarding implementation status of relevant policies and their work status, performance distribution and supervision and management, and sense of gain obtained from the contracting and desired services, respectively. The grounded theory using three levels of coding was used to systematically analyze the mechanism affecting the effectiveness of contracted family doctor services.
Through the coding, 90 concepts (such as "residents' weak health awareness"), 24 categories (such as "awareness of the contracting"), and 8 core categories (such as "capacity in primary care") were obtained. A theoretical model of mechanisms influencing the effectiveness of contracted family doctor services was constructed, mainly including the implementation deviation of policies related to contracted family doctor services, capacity of primary care, and characteristics of residents.
The effectiveness of contracted family doctor services is affected by the deviation in implementing relevant policies, the capacity of primary health services and characteristics of residents. Therefore, to improve the effectiveness of these services, it is necessary to optimize the implementation path of relevant policies, improve family doctors' capacities, and improve residents' health literacy level.
Promoting contracted family doctor services is an important way to implement tiered diagnosis and treatment, and to safeguard people's health, as well as a cornerstone of achieving Health China 2030 goals. However, the development of this system is constrained by some problems, such as contracting a family doctor but making no appointments. Many countries have introduced competition mechanisms in the supply of contracted services in different degrees to enhance the quality of family doctor services. However, China is now lack of theoretical and empirical studies about introducing competition mechanisms inthe delivery of contracted family doctorservices. We reviewed the latest developments in theoretical and empirical studies involving the use of competitive mechanisms in the provision of contracted family doctor services, which will contribute to the study and implementation of family doctor system in China.
At present, the contracting rate of family doctors in China is high, but there are problems such as low service quality and low service utilization rate.
To comprehensively investigate the current situation of contracting, performance and renewal of family doctor services in Meizhou and Heyuan cities of Guangdong Province, and explore the impact of appointment consultation service on the quality of contract services.
From July to August 2021, 11 districts and counties in Meizhou and Heyuan cities were selected using a multi-stage sampling method, the list of rural health centers that can be investigated was provided by the health bureau of each district (county). The questionnaire was administered through the "questionnaire star" platform to the head of the rural health centers or the directors of public health. The questionnaire was prepared by the Guangdong Internet + Family Doctor Contract Guidance Center, which was called "Guangdong Family Doctor Contract Service Current Situation Questionnaire", including the basic information of the invesgated rural health centers, the current situation and progress of family doctor contract service. Based on the structure-process-outcome (SPO) model, the dependent variables were set as outcome quality indicators (effective contract rate of general population/focused population, number of institutions with difficulty in compliance and low renewal rate) to compare the current situation of family doctor contract service in rural health centers with different appointment consultation service provision capacity. The Logistic regression was used to analyze the impact of appointment consultation service on the outcome quality of contract service.
The median family doctor contract rate of 100 rural health centers for focused population and general population was 69.0% (60.0%, 85.0%) and 31.8% (29.1%, 54.5%), respectively; the number of institutions reaching family doctor contract service coverage target for focused population/general population of 2025 was 42 (42.0%) and 30 (30.0%), respectively. A total of 78 (78.0%) of these 100 rural health centers faced difficulties in compliance implementation, including 38 (90.5%) rural health centers did not provide appointment consultation service; 50 (50.0%) rural health centers had problems with low renewal rates, including 18 (42.9%) of which did not provide appointment consultation service and faced difficulties in compliance implementation. Logistic regression analysis showed that among the health centers reaching the target, there was no effect the providing of appointment consultation service on the contracting rate of family doctors in the focused and general population (P>0.05) ; among the 100 investigeted health centers, the providing of appointment consultation service had a significant effect on the compliance difficulties of the contracted institutions〔OR (95%CI) =0.28 (0.08, 0.98), P<0.05〕; and the providing of appointment consultation service had no effect on the low renewal rate of contracted residents (P>0.05) .
The performance of family doctor contract service in Guangdong Province is closely related to the providing of appointment consultation service by the health cenyers, and it is recommended to enrich the form and content of appointment service in the process of subsequent service, enhance residents' trust and motivation to use the service actively through the Internet + platform "improve efficiency and quality", while injecting motivation for service provision and utilization from both doctors and patients in order to provide continuous and effective integrated medical and health services as well as health management.
With the gradual shift in the disease spectrum, chronic non-communicable diseases (hereafter referred to as "chronic diseases") have become a serious threat to health and economic development in China and globally. Due to various pathogenic factors and a long course of disease, patients with chronic diseases often have a chronic disease accumulation state of individuals suffering from two or more chronic diseases at the same time, referred to as multimorbidity. The problem of multimorbidity is becoming increasingly prominent with a younger trend. The effective integration of fragmented and discontinuous health services, which are disease-centered and treatment-based, is of great significance in addressing this problem. This paper reviewed the current research status and development trends of multimorbidity health service integration at home and abroad, and analyzed the shortcomings of the current researches and practices of integrated health care of multimorbidity. It is proposed that constructing a personalized integrated service model centered on patients with multimorbidity and exploring the quantitative evaluation practice of integrated health care of multimorbidity in the real world are the development direction of future research on multimorbidity integrated services, providing reference for realizing the efficient and sustainable integration mechanism of multimorbidity services among medical institutions in China.
In recent years, with the development of mobile medicine and telemedicine technology, health management models such as Internet hospitals, online and offline cooperation have gradually become a development trend. However, the elderly have limitations in the use of "Internet+" technology, which affects the mobile health of the elderly, and develops a remote management model based on family members, helping improve the coverage and efficiency of health management for the elderly.
To construct an "Internet+" family nursing management model for the elderly, focusing on the contracting problem of the elderly in the context of contracted family doctor services.
From June 2020 to February 2021, the "Internet+" family nursing management model for the elderly was preliminarily formulated according to the policies related to the health management of the elderly, combined with domestic and foreign literature research and preliminary basic research. Applying the Delphi method, 15 experts were selected for two rounds of expert consultation, forming the final draft of the "Internet+" family nursing management model for the elderly.
The positive coefficients of the two rounds of expert consultation were 100%, with the authority coefficients of 0.87 for both, and Kendall coordination coefficients of 0.253 and 0.226, respectively (P<0.001) . The final "Internet+" family nursing management model for the elderly consisting of 5 parts, including the service objects, management team members, the selection and training content of family caregivers, implementation method, management content with a total of 46 items was established.
This study focuses on the practical problems of elderly health management, and the "Internet +" family nursing management model constructed for the elderly not only conforms to the development of "Internet+ medical care" technology, but also realizes the participation of the elderly in remote health management, which is scientific and reliable, and can be used as a tool for remote care management of the elderly in the community.
Application Effect and Countermeasures of the Family Contract Service Model Based on "the Consortium of Rural Doctors and Community Doctors" Among the Elderly Residents in the Mountainous Area of North Beijing
The elderly residents in the mountainous area of northern Beijing have a high incidence of chronic diseases, a weak economic foundation, limited access to health knowledge, and a long distance from community health service institutions. At present, the team of family doctors in the mountainous area of northern Beijing is composed of community doctors and rural doctors. Both of them play an important role in contracting services for elderly residents in mountainous areas.
To explore the current status of family doctor contracted services in the northern mountain areas of Beijing and put forward appropriate suggestions on family doctor contracted services with the elderly residents in mountain areas.
A combination of qualitative research and quantitative research was adopted. From September to October 2019, eight townships were selected in the northern mountain areas of Huairou District in Beijing. A total of 141 community doctors, 133 rural doctors and 345 elderly residents were selected proportionally from each township for questionnaire research. The elderly resident's questionnaires included basic information of the elderly, the way and the content of services which they want family doctor team to provide, the channels to obtain health consultation, and the satisfaction evaluation of the contracted services; the rural doctors and the community doctors' questionnaires included basic information, the use of internet in the contracted services, and the content of services provided to the elderly residents. During the same period, 16 cases of elderly residents, 24 cases of community doctors, and 24 cases of rural doctors were selected by using the purposive sampling method for personal in-depth interviews, in order to understand the level of awareness of the responsibilities of community doctors and rural doctors in the linkage contracted services, their views on the contracted services and the application of the internet in this service model, their suggestions on the development of the contracted services, etc. A content analysis method was used to analyse qualitative data.
According to the quantitative research results, the top three services that elderly residents in the northern mountain areas of Beijing want the family doctor team to provide are ranked as follows: carrying out the health education in countryside〔199 (57.7%) 〕, physical examination in countryside〔197 (57.1%) 〕, the delivery of medical service and medicine in the countryside〔169 (49.0%) 〕; the top three ways or channels of services that elderly residents want the family doctor team to provide are ranked as follows: outpatient clinicservice, in-home medical services, organizing health education lectures in the community; the top three channels that elderly residents consider most effective to obtain health information are ranked as follows: publicity by rural doctors or loudspeaker in the village〔253 (73.33%) 〕, face-to-face publicity by community doctors during consultation〔134 (38.84%) 〕, posting and distribution of publicity materials〔126 (36.52%) 〕. The results of multiple linear regression analysis showed that service attitude, service effectiveness, service items, and communication ability were the influencing factors of elderly residents' satisfaction with community doctors and rural doctors' linkage contracted services (P<0.05) . The health management service, outpatient service, drug distribution and medical guidance service, and long-term prescription service also had significant differences between community doctors and rural doctors (P<0.05) . There was no statistically significant difference between community doctors and rural doctors using the Internet to communicate with residents online (P>0.05) . The qualitative research results showed that the elderly residents had low demand for online services and high dependence on rural doctors, but the technical level of rural doctors were limited, community doctors had little communication with elderly residents, and they mainly focused on the coordination of medical resources.
The development of contracted services for elderly residents in the northern mountain areas of Beijing cannot be carried out without the joint efforts of community doctors and rural doctors. Currently, the elderly residents highly depend on rural doctors because of close-up services and show a great demand on community doctors for high-level technology and medical resources platform. It's recommended to take the needs of elderly residents as the guide, give full play to the advantages of rural doctors in terms of location and people, and the advantages of community doctors' technology and platform, and optimize the effectiveness of community doctors and rural doctors' linkage contracted services.
Currently, there are many studies on family doctor contracting services from the perspective of residents, but few scholars have conducted studies on the current situation of family doctor team contracting based on the perspective of general practitioners (GPs) .
To understand the current situation of family doctor contracting services in primary health care institutions in Guangdong Province, and explore the factors affecting the contracted number from the perspective of the supplier.
From July 5—31, 2021, GPs in primary health care institutions in Guangdong Province were selected as the study subjects by using a multi-stage stratified cluster sampling method to conduct the survey with a self-designed questionnaire. The contracted number was compared by different GPs and their family doctor team characteristics. A two-level Logistic regression developed by R 4.2.2 software was used to identify influencing factors of contracted number above 2 000.
A valid sample of 3 252 cases in family doctor team with contracted number more than 100 was screened, and the median contracted number was 1 400 (2 499) in 2020. The differences were statistically significant when comparing the contracted number by gender, age, education level, position, employment form, working years, working unit, working area, training acceptance, and annual income, number of team members, population size under jurisdiction, willingness of specialists from medical community to join the team, inpatient bed resources and guidance from superior departments (P<0.05). Zero model fitting showed that contracted number was clustered at the regional level (P<0.05). Two-level Logistic regression model showed that, with master's degree or above as the reference, the contracted number of the team including GPs with college〔OR (95%CI) =2.79 (1.84, 3.74) 〕and secondary/high school〔OR (95%CI) =2.83 (1.80, 3.86) 〕degrees were more likely to be above 2 000; taking no position as reference, the contracted number of the team including unit leaders〔OR (95%CI) =0.66 (0.33, 0.99) 〕was more likely to be above 2 000; taking temporary staff as reference, the contracted number of the team including formal staff〔OR (95%CI) =2.02 (1.53, 2.51) 〕was more likely to be above 2 000; taking the team with size of 3 or less people as reference, the contracted numbers of the teams with size of 4 to 6 people〔OR (95%CI) =1.31 (1.05, 1.57) 〕, 7-10 people〔OR (95%CI) =2.06 (1.75, 2.37) 〕, 11-19 people〔OR (95%CI) =3.67 (3.31, 4.03) 〕and≥20 people〔OR (95%CI) =3.46 (2.74, 4.18) 〕were more likely to be above 2 000; taking population size under jurisdiction at 2 000 or less as reference, the contracted numbers of the team with population size under jurisdiction at 2 001 to 9 999〔OR (95%CI) =2.37 (2.12, 2.62) 〕, 10 000 to 29 999〔OR (95%CI) =2.92 (2.65, 3.19) 〕and more than 30 000〔OR (95%CI) =2.86 (2.55, 3.17) 〕were more likely to be above 2 000; taking condition of having inpatient bed resources as reference, the contracted number of the teams without such resources〔OR (95%CI) =1.38 (1.14, 1.62) 〕was more likely to be above 2 000 (P<0.05) .
The population under jurisdiction and the large number of team members create favorable conditions for contracting; family doctor teams with GPs with positions, inpatient bed resources and high education level have a good understanding of family doctor contracting service policies and control the number of contracted patients better; comparing with temporary staff, GPs team with formal staff may undertake more contracting tasks.
