A Case Study on the Integrated Healthcare Delivery System in Xuhui District, Shanghai Best Practices and Implementation

Research Background and Policy Environment

According to the World Health Organization (WHO), the global population is aging at a significantly accelerated pace compared to historical trends. The demographic cohort aged 60 years and above is projected to escalate from 1 billion in 2020 to 1.4 billion. By 2050, this geriatric population segment will have doubled, reaching 2.1 billion individuals worldwide [1]. China possesses the world’s largest elderly population, with Shanghai emerging as a paradigmatic case of pronounced population aging [2]. According to the latest statistical data of Shanghai Civil Affairs Bureau, by the end of 2023, the population aged 60 and above accounted for 37.4% of Shanghai’s total resident population. Numerous non-communicable chronic diseases, particularly multimorbidity patterns, exhibit elevated prevalence rates among its geriatric demographic, notably manifesting in cognitive impairment, diabetes mellitus, hypertension, Parkinson’s disease, and osteoporosis [3]. For instance, a nationwide study of Chinese adults aged 60 years and above revealed a cognitive impairment-diabetes gradient, with prevalence rates escalating from 26.0% in mild cognitive impairment to 36.9% in dementia cases [4].

With advancing age, the progressive decline in physiological capacity elevates susceptibility to a spectrum of age-related pathologies. The Integrated Care for Older People (ICOPE), proposed by WHO, offers a comprehensive, person-centered framework to maintain intrinsic and functional capacity through coordinated health and social services [5]. It emphasizes evidence-based, multidimensional strategies combining community interventions, cross-sectoral coordination, and personalized integration to support autonomy in older adults [6]. Unlike conventional fragmented care in China, integrated care connects medical, social, and eldercare services via multidisciplinary teams and standardized assessments, proactively addressing capacity decline and preventing avoidable hospitalizations, while reducing duplication and resource inefficiency [7].

Since 2015, the Chinese government has promulgated a series of pivotal policy documents at the national level, notably including the ‘Guidelines on Promoting Contracted Family Doctor Services’(National Health Reform Office [2016] No. 1), the ‘Guiding Opinions on Promoting the Construction and Development of Medical Consortia’ (State Council General Office [2017] No. 32), the ‘Administrative Measures for Medical Consortia (Trial Implementation)’ (National Health Commission Office [2020] No. 13) and the ‘Guiding opinions on comprehensively promoting the construction of compact county medical and health community’(Department of Primary Health [2023] No.41) [8, 9, 10, 11]. These initiatives have institutionalized a multi-tiered integrated care framework encompassing: (i) grid-based urban medical clusters and county-level healthcare networks, (ii) specialized alliances for critical diseases and scarce resources, and (iii) personalized family physician services. These align with Healthy China 2030 and the 14th Five-Year Plan’s mandates for integrated healthcare-social support systems through structural innovation.

Development and Challenges of the Practice of Combining Medical Treatment with Nursing Care

Numerous countries have initiated research on implementation frameworks and government-led plans for integrated care in the early stages. Japan’s 2012 Long-Term Care Insurance Act introduced the Community-Based Integrated Care System, scheduled for full implementation by 2025. This model integrates acute medical and long-term care services under insurance coverage to deliver continuous community-based support for older adults with chronic conditions or disabilities, while containing social security costs. It emphasizes tri-level integration (system, organization, clinical) through multidisciplinary teams including public health nurses and care managers to provide personalized, continuous care [12]. In 2015, NHS England launched the Vanguard Integrated Care Programme, later incorporated into the 2019 NHS Long Term Plan. Covering 9% of England’s population, this initiative coordinates health, social care and rehabilitation services through cross-organizational collaboration, particularly for community-based patients. Results showed a 6% slower growth rate in emergency admissions across 23 pilot sites compared to controls, demonstrating effective hospital demand management [13]. The INSPIRE study in Toulouse, France demonstrated that implementing WHO’s ICOPE model that focuses on five intrinsic capacity (IC) domains (mobility, cognition, nutrition and vitality, psychology, sensory) effectively replaces disease-centered care. Key findings revealed significant associations between biological aging markers and IC decline, supporting biological interventions to preserve function [14]. An integrated care programme that was mandated by the UK’s General Medical Services contract uses a standardized electronic assessment, the Luton Framework for Frailty (LFF), to identify frailty in older adults and automatically link them to tailored interventions [15, 16].

The evolution of integrated care research in China has progressed through three distinct developmental phases: the incipient stage (2000–2007), characterized by theoretical germination and conceptual exploration; the exploratory stage (2008–2015), marked by systematic investigations into context-appropriate integrated models and multi-stakeholder interest coordination mechanisms; and the maturation stage (2016–2020), during which researchers not only delineated implementation challenges but also advanced pragmatic solutions, including shared governance frameworks and person-centered service delivery models to address systemic fragmentation [17]. Multiple studies have pointed out that there is a lack of systematic integration among medical, elderly care, psychological, and social services in China [18, 19, 20]. Information silos are widespread, leading to repeated medical visits, resource wastage, and fragmented care for older adults. Care workers and primary healthcare providers often lack sufficient capabilities in managing multimorbidity, cognitive impairment, and providing psychological support, which negatively impacts service quality. The concept of “integrated care” is subject to varying interpretations across sectors, and the absence of standardized training frameworks has contributed to a significant shortage of adequately trained professionals in the field [18, 21].

Assessment tools and service models also lack localization and standardization. For example, while the ICOPES-TW screening tool demonstrates feasibility, it remains in the early validation phase and has not yet been widely adopted in community or institutional care settings. The absence of unified evaluation indicators and service processes leads to inconsistencies in care quality and hinders scalability [21, 22]. The LFF assessment tool has only been studied in the context of implementation in the UK, and it has not yet been introduced to China [23, 24]. In government procurement of services, resource allocation still prioritizes cost control over outcomes such as user satisfaction or care effectiveness, failing to reflect a people-centered investment approach [22]. Additionally, older adults and their families generally have limited awareness of integrated care services. Some continue to place greater trust in traditional medical or home-based care models and express uncertainty or reluctance toward multi-sectoral, collaborative approaches [18]. As a result, the common challenges facing the development of integrated care in China include: service fragmentation, insufficient primary care capacity, lack of standardized tools and models, unclear performance-based funding mechanisms, and low public acceptance.

Innovation of “Six-Bed Integration” Model in Xuhui District

As one of Shanghai’s top five most aged central districts, Xuhui District recorded a 36.45% proportion of residents aged 60 and above in 2022. The “9073 model” is an eldercare framework where 90% of seniors receive home-based care, 7% utilize community services, and 3% reside in institutional facilities in Shanghai [25]. Since 2024, Kangjian Subdistrict in Xuhui District has piloted an innovative “Six-Bed integration” model, which reconfigures the traditional “9073” eldercare framework by integrating three types of medical beds (home-based, rehabilitation/palliative, and hospital beds) with three types of care beds (home care, day care, and institutional care). This model enables dynamic allocation of service resources and addresses the fragmentation of care settings within the conventional “9073” system [26]. Anchored by the Kangxin Integrated Eldercare Center and the community health service center, the model establishes cross-setting service pathways: home-based older adults receive medical support via home beds; day care centers coordinate with rehabilitation beds for functional training; and institutional care is linked with palliative beds to form a closed-loop end-of-life care system.

The integration mechanism operates on three levels: (1) tiered response to needs: priority support is provided to high-risk older adults living alone (e.g., 2,260 targeted individuals) through coordinated home care and home medical beds; (2) intelligent resource allocation: digital platforms enable streamlined referrals between medical and institutional beds; and (3) progressive service continuity: day care users can transition to medical or rehabilitation beds as care needs escalate.

This model is led by the Xuhui District Civil Affairs Bureau, in collaboration with the District Health Commission and the Medical Insurance Bureau, forming a tripartite coordination mechanism characterized by “civil affairs leadership, health commission collaboration, and medical insurance support.” The specific division of responsibilities is as follows: the civil affairs department is responsible for integrating elderly care bed resources and establishing service standards; the health department oversees medical services for home-based hospital beds, rehabilitation beds, and palliative care beds; and the medical insurance department is tasked with exploring payment methods aligned with integrated care [27].

Research Questions

Given the innovative yet under-examined nature of the “Six-Bed Integration” model, this study addresses the following core question: How does the “Six-Bed Integration” model operate in practice, and what are the key barriers to its successful implementation? As a pioneering initiative in one of China’s most aged urban districts, this case study seeks to provide critical insights into the real-world integration of healthcare and eldercare services, with implications for policy and practice both nationally and internationally.

Research Subjects

Purposive sampling was employed to select staff members: (1) at least half a year of involvement in the multi-bed integrated care program in Kangjian Subdistrict since September 2024, and (2) at least two years of work experience in medical or eldercare services. Exclusion criteria: (1) non-participation in the multi-bed integrated care program, and (2) unwillingness to provide informed consent for the interview. Based on these criteria, 15 staff members were selected as respondents (coded N1–N15). Sociodemographic characteristics of participants are presented in Table 1.

Interview Guide Development

Semi-structured interviews were conducted for data collection. An interview guide was drafted based on research objectives and a review of relevant domestic and international literature [28, 29, 30]. In particular, the framework proposed by Zhang et al. [30], which delineates factors influencing experiences, including environmental design, individual perceptions, and interpersonal interactions, served as a basis for formulating questions on service coordination and continuity. Additionally, evidence from studies addressing implementation challenges, such as Li et al. [28, 29], and Arku D et al. [28, 29], on workforce capacity and multidisciplinary collaboration, provided critical insights for shaping questions related to current service outcomes and future development directions. Input from experienced healthcare professionals and long-term eldercare service providers was incorporated. Two staff members were pre-interviewed to refine the content before finalizing the guide. Key questions included:

• How does Kangjian Subdistrict’s integrated healthcare and eldercare system coordinate community, home-based, and institutional services?

• Within the six-bed integration system, how is effective referral and continuity ensured across different service beds?

• What are the current outcomes of integrated healthcare and eldercare services? Are there evaluation data or case studies to share?

• What are Kangjian Subdistrict’s future plans and development directions for integrated healthcare and eldercare?

• How can service coverage and quality be further improved to better meet older adults’ needs?

Data Collection Methods

One-on-one semi-structured interviews balanced preset research frameworks with participant narrative flexibility. After obtaining consent, interviews were conducted offline face-to-face at agreed times/locations. Researchers explained the study’s purpose, content, and significance beforehand. Each interview averaged 45 minutes, with audio recording (participant-approved) and non-verbal cues documented. All recordings were kept confidential. Fifteen interviews were transcribed verbatim. Colaizzi’s systematically extracts meanings from lived experiences, clusters themes on structural and coordination challenges, and validates findings with participants, ensuring rigor and credibility in exploring the complex dynamics of the Six-Bed Integration model [31, 32, 33]. This study employs Colaizzi’s seven-step phenomenological method to systematically analyze the interview data. Following Colaizzi’s seven-step method, transcripts were read repeatedly to grasp overall meaning. Significant statements were extracted and meanings formulated. These were organized into theme clusters reflecting barriers and coordination challenges. The findings were integrated into an exhaustive description, which was then condensed into essential structures. Finally, results were returned to participants for validation, ensuring accuracy and credibility.

Kangxin Integrated Elderly Care Service Center (Xuhui District, Shanghai)

Affiliated with Kangjian Subdistrict, Kangxin Center launched a pilot in September 2024 with support from the District Civil Affairs Bureau and Health Commission. It integrates medical, rehabilitation, and eldercare resources for community and institutional settings, tailoring services to diverse needs. As the hub of Kangjian’s integrated healthcare-eldercare system, it coordinates all local eldercare and medical resources, providing outreach, education, counseling, referrals, and daycare—forming the core of the six-bed integration.

Kangjian Community Health Service Center (Xuhui District, Shanghai)

As Shanghai’s first integrated healthcare-eldercare pilot subdistrict, Kangjian established its system and six-bed integration model to deepen service integration. The center manages three beds: eldercare beds, home-based hospital beds, and rehabilitation/palliative care beds (primary hospital treatment beds). Through Kangxin Center, families’ needs and seniors’ conditions are assessed for eligibility. Recognized as a national model, Kangjian’s “six-bed integration” is illustrated in the two-way referral pathway (Figure 1). It links family medical, rehabilitation/palliative, hospital, eldercare institution, day care, and home care beds, bridging institutional, community, and home-based services. The two-way referral operates across all bed types, enabling older adults to shift flexibly between care settings as conditions change, ensuring continuity, reducing fragmentation, and achieving seamless upward and downward transfers.

Figure 1

Resident Health Profile

The center has established a comprehensive public health system through integrated medical-education-research collaboration and community-hospital partnerships, emphasizing prevention and lifelong health management. Supported by electronic health records and 5G technology, it delivers end-to-end services from profiling and screening to treatment and education. Coverage has reached 92.35% of the subdistrict’s 96,000 residents, with full registration for 39,591 contracted residents and dynamic updates for 82.15%. Services for priority groups are notable: 21,389 pediatric visits (99.3% coverage), early prenatal registration for 296 women, and targeted support for 2,512 octogenarians (including 13 centenarians) and 151 bereaved families. Chronic disease management has achieved standardized control rates of 88.49% for hypertension (13,720 cases), 90.46% for diabetes (4,531 cases), and 99.04% for mental health conditions. These outcomes highlight the center’s capacity to deliver high-quality, precision public health services, advancing its vision of preventive, full-cycle health governance.

Collectively, the development of Kangxin and Kangjian centers, together with the Resident Health Profile, consolidates rich databases, digital management, and skilled nursing teams, providing essential infrastructural and professional support that underpins the effective piloting and advancement of the Six-Bed Integration model.

Case Study Analysis

Key Challenges

Synergistic Effects and Structural Contradictions in Resource Integration

The practice of integrated eldercare and healthcare demonstrates multi-level spatial restructuring characteristics. Community health center staff explicitly stated: “The Medicare restrictions on bed turnover are the fundamental contradiction—we have no authority to discharge patients, but Medicare strictly regulates us” (N1). This institutional tension is particularly evident in the “Six-Bed Integration” model. Although the parallel deployment of home medical beds and home care beds theoretically achieves “seamless medical-eldercare integration” (N3: “family physicians provide regular home visits”), rehabilitation bed operators lamented: “Demand overwhelms capacity. Referred seniors without guardians don’t meet admission criteria, exposing us to malpractice risks” (N13). Notably, the embeddedness of family doctor teams in nursing homes was termed “service microcirculation” (N2), yet this innovation faces resource constraints: “As the city’s pilot site, our three medical beds (rehabilitation, hospice, and home-care beds) are perpetually insufficient” (N1). Key challenges in the Kangjian Subdistrict’s Six-Bed Integrated Care Network are illustrated in Figure 2.

Figure 2

The involvement of social forces reveals boundary disputes in public service delivery. While third-party organizations alleviate “bed shortages that may trigger disputes” (N4), nursing home administrators highlight deeper systemic gaps: “We lack clarity on follow-up services from senior care centers, making referrals risky” (N13). Such distrust reflects institutional ambiguities between market-based supplementation and public accountability.

Institutional Barriers and Structural Contradictions in Resource Integration

Institutional barriers in resource integration arise from disconnects between policy frameworks and service realities. Rigid healthcare insurance mechanisms conflict with the extended care needs of frail elderly populations. For example, risk-averse admission protocols systematically exclude unaccompanied seniors. These systemic failures are compounded by weak multi-sector coordination. Information gaps persist in cross-institutional referrals, and care facilities shoulder disproportionate risks because legal frameworks for shared accountability are absent. Artificial scarcities also persist. Pilot medical beds fail to meet community demand, and compulsory hospital discharge timelines clash with limited facility capacity. This produces a governance trilemma: cost containment through bureaucratic control, equitable access, and quality assurance cannot all be achieved simultaneously.

Similar challenges are seen internationally. In France, elderly care integration pilots are frequent, but they are led by siloed administrative bodies without horizontal coordination or accountability mechanisms. Local practitioners attempt “integrative piloting” to bridge systemic gaps. Yet, without national legal support, collaboration depends heavily on personal networks and individual initiative, preventing large-scale integration [34].

Structural barriers also include fragmented discharge planning by non-governmental organizations, limited facility capacity, and unclear role definitions. These factors create information discontinuities and concentrate risks on single actors, highlighting the lack of a cross-sector risk-sharing framework [35]. Ultimately, institutional paralysis stems from three unresolved tensions: mismatches between segmented administrative systems and continuous care needs, the absence of cross-sector risk mitigation mechanisms, and chronically ambiguous legislative mandates for integrated care models [36]. Although this study primarily adopts a qualitative approach, preliminary findings—supplemented by pilot data from the Kangjian Community Health Service Center in 2024 (e.g., a 21% increase in home-based hospital bed utilization and a 56% success rate in referrals to elderly care institutions)—suggest the model’s potential to enhance service accessibility and resource utilization efficiency. Future research should incorporate quantitative indicators (such as bed turnover rates, patient satisfaction, and changes in medical costs) to further validate its incremental value.

Service Accessibility and Fracture of Information Dissemination

The accessibility of services is structurally undermined by systemic discontinuities in information dissemination, where critical care resources remain operationally disconnected from target populations due to fragmented communication channels and uncoordinated outreach mechanisms. This rupture manifests through two interdependent dimensions: physical information barriers that exclude bedbound elders from service awareness, and cognitive translation failures wherein words like ‘daycare beds’ is misinterpreted by intended beneficiaries. The disjunction is further exacerbated when digital outreach platforms assume family mediation roles without establishing necessary intergenerational communication infrastructures, sunch as unestablished WeChat groups, while cultural mismatches in health messaging, such as divisive perceptions of “Kang Xiao Yang” mascots, reveal unaddressed sociolinguistic variances across communities. Research indicates that virtual healthcare visits demand a high level of technological proficiency, yet many socially vulnerable seniors face significant barriers related to limited access to technology and inadequate training—such as lacking assistance in operating devices or being unable to join WeChat groups [37].

Language barriers and low health literacy are found to be closely associated with poor self-rated health. Even when linguistically concordant healthcare services are provided, issues of cultural mismatch remain insufficiently addressed [37]. Ultimately, this represents not merely an information gap but a fundamental collapse in the care continuum’s communicative architecture, where unshared needs inventories between neighborhood committees, property managers, and service providers institutionalize exclusion through bureaucratic silos rather than technical limitations.

Referral Mechanism and Reconstruction of Power and Responsibility System

The referral mechanisms and accountability systems require fundamental restructuring. This is evident in the operational tensions within the “Six-Bed Integration” model in Xuhui District. Systemic dysfunction arises when hospital discharge protocols, such as medical insurance restrictions on bed turnover, conflict with the risk-averse practices of nursing institutions. These facilities often refuse admission to unaccompanied elderly patients. This misalignment produces a contradictory situation. Hospitals are penalized for retaining patients beyond the permitted period. Downstream care providers reject medically stable elderly individuals because of liability concerns. Community health centers lack binding authority to enforce transitional care. The result is an accountability vacuum that shifts the burden to family caregivers and perpetuates long-term bed-blocking crises.

Three dimensions of governance failure are exposed. First, there is a mismatch between discharge schedules and placement delays (time). Second, responsibility is distributed asymmetrically across institutions (risk). Third, enforcement authority remains unclear (jurisdiction). Social disadvantages, such as living alone, further increase the likelihood of nursing home admission after discharge. This reveals a weak integration of social support and medical assessment, which shifts responsibility from hospitals to care institutions and worsens bed-blocking problems [38].

More broadly, the elderly care system suffers from widespread institutional misalignments. Policies and regulations are inconsistent. Responsibility is spread across multiple actors. Collaboration between organizations is weak, and information exchange is inadequate. These mismatches reduce efficiency, obstruct coordination, and prevent shared accountability [39]. The findings echo international evidence on barriers to integrated care. Yet, they also highlight a uniquely Chinese tension between vertical administrative control, enforced through health insurance performance assessments, and the horizontal need for service integration.

Theoretical Enlightenment and Practical Innovation

The “Six-Bed Integration” case exemplifies the distinctive challenges China faces in developing an integrated eldercare system, specifically, a threefold mismatch involving bureaucratic efficiency imperatives, deeply rooted familial care traditions, and the rapid emergence of market mechanisms. These tensions are further intensified by the demographic reality of hyper-urban aging, as illustrated by Xuhui District’s population, where 36.45% are aged 60 and above.

Although China shares certain structural challenges with international models—such as Japan’s Community-Based Integrated Care System, which seeks to balance insurance constraints with continuity of care, or England’s Vanguard Programme, which enhances cross-sector coordination and reports a 6 percent reduction in emergency admissions—the Xuhui model offers unique contrasts. While all face issues of coordination and accountability, Xuhui highlights acute pressures from rapid urban aging, uneven insurance coverage, and limited community capacity. These lessons are particularly relevant for low-resource settings, where targeted referral protocols, digital monitoring, and shared risk-pooling mechanisms can provide scalable pathways to sustainable integrated care.

China’s situation is marked by three uniquely intensified pressures. First, the policy timeline is unusually compressed, as the country attempts to address decades of aging-related challenges within a matter of years. Second, there exists a pronounced asymmetry in resource distribution, particularly between well-resourced tertiary hospitals and underdeveloped community care infrastructure. Third, the allocation of care responsibilities remains unresolved, with ongoing ambiguity over the roles of the state, market, and family caregivers.

Policy Implications

The findings reveal structural contradictions within the integrated care system at the institutional, service, and referral levels, offering clear directions for policy development. In the short term, it is necessary to establish mandatory referral coordination mechanisms and a digital bed-monitoring platform, while piloting a “risk-pooling fund” jointly supported by medical insurance, civil affairs, and care institutions to address admission challenges for unaccompanied older adults [38, 39]. In the long term, reforms should promote the integration of medical insurance and long-term care insurance funds, with capitation-based payments for integrated service packages; establish a specialized track in “Geriatric Integrated Care” within medical schools to train interdisciplinary teams; and legislate for the sharing of electronic health records alongside unified service quality evaluation standards to ensure continuity of care [40, 41]. These measures aim to resolve the tension between vertical administrative control and horizontal service integration, thereby building a sustainable integrated care system.

Research Limitations and Future Directions

This study has three main limitations. First, the sample lacked representativeness, with only 15 professionals interviewed and limited inclusion of family or elderly perspectives, weakening user-side analysis. Second, the absence of process indicators like bed turnover and referral success rates restricted precise evaluation of system efficiency. Third, A limitation of this study is the lack of methodological triangulation to further enhance the validity and reliability of the findings.

Future research may explore micro-level issues such as quantifying resource misallocation and communication failures, and system-level tensions by applying collaborative governance theory to examine interactions among healthcare, eldercare institutions, and communities. The study sample primarily consisted of participants from community health service centers (80%) and elderly care institutions (20%), with no representation from other organizations such as medical insurance departments, civil affairs management agencies, or other relevant government departments. This sample composition may limit the in-depth understanding of cross-sectoral collaboration mechanisms and policy-level challenges. Future research should include a broader range of policy makers and implementing entities.