Table 1
Sociodemographic Characteristics of Participants (N = 15).
| CHARACTERISTIC | CATEGORY | COUNT (n) | PERCENTAGE (%) |
|---|---|---|---|
| Gender | Female | 14 | 93.3 |
| Male | 1 | 6.7 | |
| Age (years) | 20–29 | 2 | 13.3 |
| 30–39 | 5 | 33.3 | |
| 40–49 | 8 | 53.3 | |
| District | Xuhui District | 15 | 100.0 |
| Institution | Kangjian CHSC | 12 | 80.0 |
| Kangxin Elderly Care | 2 | 13.3 | |
| Zhongque Elderly Care | 1 | 6.7 | |
| Professional Title | Senior Title (Associate Chief Physician/Senior Nurse) | 4 | 26.7 |
| Intermediate Title (Attending Physician) | 3 | 20.0 | |
| Junior Title (Junior Staff) | 5 | 33.3 | |
| Other (Social Worker, etc.) | 3 | 20.0 | |
| Education | Bachelor’s Degree | 14 | 93.3 |
| Master’s Degree | 1 | 6.7 | |
| Years of Experience | ≤5 | 4 | 26.7 |
| 6–15 | 4 | 26.7 | |
| 16–25 | 6 | 40.0 | |
| ≥26 | 1 | 6.7 |
[i] Note: CHSC = Community Health Service Center. Percentages are calculated based on the total sample size (N = 15) and may not sum to 100% due to rounding.
Figure 1
Kangjian Subdistrict’s Six-Bed Integrated Care Network (Xuhui District, Shanghai).
(Eldercare services include: Institutional beds (Xuhui Social Welfare, Xinle Elderly Care, Kangjian Nursing Home, Changqingfang & Shouchangfang Care Centers); Home care beds (Xuhui No.3 Senior Welfare, Shouchangfang Center); Day care at Kangxin Senior Service Center; Medical services through Kangjian CHC (family/rehab/palliative beds) and Shanghai 8th People’s Hospital; Dingxiangyuan Senior Center currently vacant. The cross-institution referral process is coordinated by the Kangjian Subdistrict Integrated Elderly Care Service Center as the central hub. Through a joint assessment team (including family physicians, heads of elderly care institutions, and social workers), it conducts needs assessments and bed matching to achieve closed-loop management of “assessment-referral-admission-feedback.”).
Table 2
Participant Characteristics by Service Type.
| NAME | SERVICE TYPE | AGE | GENDER | OCCUPATION | CHRONIC CONDITIONS | CARE RISKS* | PATIENT HEALTH STATUS AND CARE SETTING TRANSITIONS |
|---|---|---|---|---|---|---|---|
| Patient A | Community-Based Patient Transfer to Daycare Respite Service | 73 | Male | Secondary school teacher | Diabetes | None | A 72-year-old male with long-term diabetes mellitus residing in Community A was referred to Kangxin Integrated Elderly Care Service Center’s daycare program. Previously institutionalized at a long-term care facility, the patient (with a history of diabetic toe amputations and mobility impairment) was transitioned to daycare services on December 6th following hospital discharge. His spouse reported difficulties in providing adequate home care due to age-related limitations and frequent absences, particularly concerning fall risks and environmental hazards. The daycare program provided professional supervision, cognitive-physical activities, and social engagement opportunities. |
| Patient B | 88 | Male | Military veteran | Hypertension | None | An elderly couple from Community B demonstrated significant lifestyle improvement after enrolling in Kangxin’s services in July 2024. Prior to engagement, their daily activities were limited to essential shopping and walking. Post-enrollment, they regularly participated in structured activities (handicrafts, calligraphy, reading, and film therapy), which enhanced social connectivity and mental stimulation, culminating in their formal appreciation through commendation letters. | |
| Patient C | 86 | Female | Warehouse administrator | Hypertension | Moderate cognitive impairment | ||
| Patient D | 81 | Male | Design institute engineer | Hypertension | None | A married couple faced institutional care barriers due to geographical separation, with the wife previously residing in a nursing home in Qingpu District. After learning about Kangjian Subdistrict’s six-bed integration system in September 2024, they opted for daycare services following comprehensive geriatric assessment (including physical function, self-care capacity, and cognitive risk evaluation). The wife now receives daily professional care with non-pharmacological cognitive interventions while maintaining nighttime cohabitation. | |
| Patient E | 77 | Female | Food factory clerk | Diabetes, Parkinson’s disease | Mild cognitive impairment risk | ||
| Patient F | Transfer from Elderly Care Service Center to Senior Care Facility Bed | 77 | Female | University professor | Spinal injury, Scoliosis, Osteoporosis | None | A homebound, medically fragile solo ager without guardians applied for palliative care admission after learning about the program through official media. Following a February 12 home assessment and care coordination, the patient was admitted to Xinle Nursing Home for enhanced medical accessibility. |
| Patient G | Transfer from Rehabilitation Bed to Senior Care Facility Bed | 76 | Female | Unemployed | Cerebral infarction | None | A bedbound, nonverbal patient (Long-term Care Insurance Level 6) was transferred from Kangjian Community Health Center to Xinle Nursing Home on October 11, 2024, requiring complete assistance with activities of daily living (ADLs). |
| Patient H | 85 | Female | Unemployed | Lumbar fracture | None | An alert, verbally communicative patient (Long-term Care Insurance Level 3) with preserved ADL capacity was transitioned to Xinle Nursing Home in March 2025. | |
| Patient I | Transfer from Home-Based Hospital Bed to Rehabilitation Care Bed | 92 | Female | Professional technician | Diabetes, Hypertension | High pressure ulcer risk | Two patients were transferred from home-based hospital beds to Kangjian’s rehabilitation units in March 2025: one in critical condition with somnolence (Case 8, March 3), and another stabilized with partial ADL independence (Case 9, March 12). |
| Patient J | 93 | Male | Unemployed | Diabetes, Hypertension | None |
[i] Note: * The Patient Care Risk Assessment Form covers nine items: falls, falling from bed, choking, accidental ingestion of medications/food, harm to self or others, burns, wandering/getting lost, pressure ulcers, and recreational activity-related accidents.
Figure 2
Key Challenges in the Kangjian Subdistrict’s Six-Bed Integrated Care Network.