我国社区居家医养结合服务实践模式：评价、优选与实施效果研究

【作者】 高鹏；

【导师】 杨翠迎；

【作者基本信息】 上海财经大学 ， 社会保障， 2023， 博士

【摘要】 人口老龄化是全世界亟需应对和解决的重要现实问题。党的二十大报告提出了“积极应对人口老龄化”的国家级战略方针,明确了老龄化问题的迫切性和长期性。养老服务问题的核心在于老龄化程度的提高使得老年人寿命得以延长,在退休与日常生活中需要面对疾病、失能残疾、生活照料和健康护理等风险,进而使得老年人对于养老服务、医疗服务与健康护理服务的需求加大。我国老年人口规模大、老龄化程度快,未来养老的负担将进一步加剧,亟需具备经济、便捷、康复、护理功能的“医养结合”服务,以满足老年人“医-养-康-护-临终关怀”的连续性健康养老服务需求,而社区居家医养结合服务是最重要的一种供给形式,其旨在提供“以居住地为中心,社区和家庭服务为半径”的可持续性健康养老、照料与医疗护理服务,其便捷的服务供给形式与宽泛的人群覆盖范围,迅速成为了医养结合服务的主流模式。同时,我国目前已基本形成了以“居家为基础、社区为依托、机构为补充”的多层次养老服务体系,这一特殊的供需结构特征也凸显了社区居家医养结合服务的重要性。因此,积极推广社区居家医养结合服务在现阶段具有重要的意义。目前,我国在社区居家医养结合服务的发展和实践中取得了一些经验,但总体上仍处于初步探索阶段。社区居家医养结合服务发展不平衡、不充分的现状没有改变,且迄今仍未能形成发展成熟、可复制、能满足当下需求的可推广型应用模式。从既有的研究来看,缺乏对社区居家医养结合服务的学理性诠释,没有深入探寻社区居家医养结合服务的理论基础及其对应的实践机制,也未能以社区居家医养结合服务的实践模式为研究出发点,对我国在社区居家医养结合服务发展过程中已取得的经验进行系统的梳理、归纳和提炼,并构建科学的评价指标体系对实践模式进行全方位综合评价,进一步实现模式的优选与实施效果检验,以遴选出具有中国实践特色的典型的、兼顾理论意义与实践特征的可推广、可复制的成熟型社区居家医养结合服务实践模式。据此,本文在拓展卡尔·波兰尼提出的“嵌入性”理论分析框架对于诠释跨部门协作机制基础上,融合了协同理论、健康老龄化理论和社会生态系统理论等理论内涵,以“模式分类-综合评价-模式优选-效果检验”为研究逻辑主线,提出了一种我国社区居家医养结合服务实践模式的“嵌入分类-综合评价-模式优选-效果分析”系统性分析框架,旨在于综合系统评价分析、案例分析、质性分析、实证分析并结合实地调研、访谈等方法,分析提炼出我国社区居家医养结合服务的优选模式,并进一步对优选模式进行实施效果检验,形成由理论到实践层面的连续性深入研究,为进一步总结、优化和推广更加符合我国当下需求的社区居家医养结合服务模式提供理论指导和决策参考。具体而言,包括如下几个方面:第一,基于人口老龄化发展的阶段性特征和老龄化程度加剧所面临的严峻形势为背景,以我国医养结合服务的发展现状和社区居家养老服务的特点为依据,分析了我国社区居家医养结合服务的必要性、发展历程和存在的问题,在对国内外文献进行回顾梳理的基础上,明确了本文的研究意义、研究思路和研究方法。第二,从养老服务、医养结合服务和社区居家养老三个角度阐述了本文的核心概念,并基于健康老龄化理论、新公共服务理论、嵌入理论和协同理论等理论视角系统地阐述了社区居家医养结合服务的理论逻辑、理论内涵及其所对应的实践机制,并以“模式分类-综合评价-模式优选-效果检验”为研究逻辑主线,构建了我国社区居家医养结合服务实践模式的“嵌入分类-综合评价-模式优选-效果分析”的理论分析框架,为后续研究提供理论支持。第三,从我国社区居家医养结合服务的发展、试点、确立、实践做法、服务享受与意愿情况等方面对我国社区居家医养结合服务的现状进行了分析,归纳总结了当下我国社区居家医养结合服务在实践中亟需解决的主要问题。进一步地,利用2019年国家卫生健康委员会与世界卫生组织共同开展的“医养结合在中国的最佳实践”中的实践案例,以嵌入理论为依据提出并构建了一个简单的“双向协同嵌入”分析框架,利用扎根理论在尝试分析社区居家医养结合服务实践模式理论层面一般特征的基础上,提炼总结了我国社区居家医养结合服务的实践模式分类,即“社区居家养老服务整合嵌入模式”、“社区基层医疗卫生服务整合嵌入模式”以及“互联网+医养结合”平台整合嵌入模式。第四,提出了一种“整体-系统-主观”的三维评价分析框架,分别从实践模式的整体环境效果、“投入-产出”效率以及模式的主观评价角度分别使用社区居家医养结合服务环境评价指数模型、DEA-Malmquist指数模型以及AHP-德尔菲法,对三类社区居家医养结合服务实践模式进行全面系统的综合评价。研究发现,社区基层医疗卫生服务整合嵌入模式的环境发展指数变化趋势显著高于社区居家养老服务整合嵌入模式;从DEA-Malmquist指数模型的分析结果来看,社区居家医疗服务整合嵌入模式的全要素生产率上升趋势较社区居家养老服务整合嵌入模式更为明显,且在回归分析结果中亦表现为这一特点;使用AHP-德尔菲法分析后发现,社区基层医疗卫生服务整合嵌入模式在相比较于社区养老服务整合嵌入模式而言其实践效果更佳,而“互联网+医养”平台整合嵌入模式则兼顾社区居家养老服务嵌入和社区基层医疗服务嵌入两类模式的实践特征。第五,依据评价研究结果并结合实地调研所获取的一手数据材料,提出并构建了基于社会生态系统理论的社区居家医养结合服务实践模式运行机制分析模型(SQ-SES),深入剖析三类实践模式在的资源系统(RS)、资源单位(RU)、治理系统和行动者(A)核心子系统及其相互之间的运行机制,并对其进行实践路径还原、分析和比较。研究发现,社区基层医疗卫生服务整合嵌入模式在协同过程中表现出了“双向嵌入”的特点,不仅可以由社区医疗护理服务机构通过机构签约为日间照料、社区养老服务机构或居家社区老年人提供专业的基层医疗护理服务(如家庭医生签约、家庭病床、慢病管理、双向转诊等),也可以由社区基层医疗服务机构其内部设立的养老服务机构/床位,为有需求的老年人提供更加多元化的医疗护理服务。这一实践措施打破了其他模式单一实践的弊端和不足。该模式具备良好的资源禀赋,在模式的综合评价中体现出较好的结果,实践模式的效率显著优于其他模式,无论是资源供给层面还是主观评价层面,其分析结果均较为显著。第六,从我国人口老龄化、健康老龄化、家庭结构变化与养老服务高质量发展等阶段性特征为背景,以健康老龄化理论为依据,利用北京大学中国健康与养老追踪调查(China Health and Retirement Longitudinal Study,CHARLS)2011、2013、2015和2018四期面板数据,基于2016年国家级医养结合服务试点为准自然实验,利用双重差分法(DID)实证检验了优选模式(社区基层医疗卫生服务整合嵌入模式)的实施效果。具体而言,在考虑其异质性特点及其相应的实践机制的同时,重点从微观个体效用层面论证实践模式对于老年人个体(身体机能、健康自评、精神抑郁水平)、健康与医疗服务利用(基层首诊、医疗总支出、个人医疗支出)以及代际照料层面(子女照料概率、间接照料支出)的实际影响,并进一步论证了区域异质性,在此基础上实证检验对比了其他两种实践模式在个体层面以及代际层面上所带来的效果差异,旨在于全面系统的评估优选模式的实施效果、影响机制及其宏观层面的影响。不同于既有的文献,本文聚焦于我国社区居家医养结合服务的实践模式研究,在深入剖析社区居家医养结合服务主体行为逻辑及其实践机制的基础上实现了以“问题诠释-经验归纳-模式评价-效果分析”为主体的问题导向型研究,拓展了社区居家医养结合服务模式协作过程中的理论逻辑内涵,并在研究视角、研究方法、材料数据获取以及政策建议方面打破了既有文献的局限性,总体上丰富了医养结合的实践研究。相比较与既有文献,本文的边际贡献在于:在研究视角上,以卫健委联合世界卫生组织发布的典型案例以及课题组进行实地调研、访谈数据为一手数据材料,能系统全面地反映现阶段我国社区居家医养结合服务的总体情况,打破了学界对医养结合研究的碎片化、模块区域化和视角片面单一的问题;在研究方法上,以跨学科协作基础,实现研究方法之间的交互协同,综合运用定量研究、定性分析、田野调查、案例分析等研究方法,“由点至面”全面和评估我国社区居家医养结合服务实践模式的实施效果;在结论上总结并凝练现阶段更符合我国实践特色的模式优化路径,形成了由理论到实践层面的连续性深入研究,为改进和优化我国社区居家医养结合服务模式发展提供理论指导和决策参考。基于上述研究,本文提出了如下建议:首先,进一步拓宽社区基层医疗卫生服务整合嵌入模式对于社区居家医养结合服务中的整体性嵌入作用,理顺其资源整合逻辑与服务供给逻辑,确立和巩固社区基层医疗卫生整合嵌入模式在社区居家医养结合服务中的核心作用,进一步把握好社区基层养老服务整合嵌入模式和“互联网+医养”平台整合服务两大实践模式的各自优势,在丰富其嵌入形式的基础上,积极利用互联网整合平台,实现实践模式之间的协作机制和不同服务群体层面的转换。进一步地,优化社区居家医养结合服务资源供给端的资源整合逻辑与服务精准化供给逻辑,在现有模式基础上,提高优选模式与不同需求层次老年人的匹配程度,实现社区居家医养结合服务的精准化供给;其次,要进一步实现社区居家医养结合服务模式的细化与分类,从社区居家医养结合服务模式的主体逻辑框架入手,在现有的优选模式上进一步实现“紧密型”“松散型”与“中间型”三类模式亚型细化,并通过建立社区居家医养结合服务第三方信息整合平台、强化社区居家医养结合服务的政策、资金、硬件设备等支持体系建设,巩固和确立社区居家医养结合服务实践模式的优化、提炼和推广的动态协作机制。在未来,更应当注重社区居家医养结合服务的供给范畴和需求层次,实现广覆盖的基础上,进一步从模式分类层面实现社区居家医养结合服务的多层次、跨区域覆盖、注重人口老龄化的综合变动趋势,动态调整不同健康层次需求老年人与实践模式的契合机制,实现医养结合服务与人口结构、家庭结构变迁等外界因素变化的相结合,将医养结合服务模式的优化、发展与实践纳入到养老服务与人口老龄化阶段的长期任务,使医养结合服务的综合发展与服务能力不断得以提升,切实为积极应对人口老龄化发挥作用。更多还原

【Abstract】 The aging population is an important practical problem that the world urgently needs to address and solve.The report of the 20th National Congress of the Communist Party of China proposed a national strategic policy of "actively addressing population aging",clarifying the urgency and long-term nature of the aging problem.The core issue of elderly care services lies in the increasing degree of aging,which prolongs the lifespan of elderly people.In retirement and daily life,they need to face risks such as illness,disability,daily care,and health care,thereby increasing the demand for elderly care services,medical services,and health care services.China’s elderly population is large and rapidly aging,and the burden of old-age care will be further aggravated in the future.It is urgent to have an economic,convenient,rehabilitation,and nursing function of the "combination of medical care and nursing" service to meet the elderly’s continuous demand for health care and elderly care services of "medical care,health care,nursing care-Palliative care care".Community home care and nursing services are the most important form of supply,Its aim is to provide sustainable healthy elderly care,care,and medical care services centered around the place of residence and within the radius of community and family services.Its convenient service supply form and broad population coverage have quickly become the mainstream model of integrated medical and elderly care services.At the same time,China has basically formed a multilevel elderly care service system based on "home as the foundation,community as the support,and institutions as the supplement".This special supply and demand structural feature also highlights the importance of community home medical and elderly care integrated services.Therefore,actively promoting the integration of community home care and medical care services is of great significance at this stage.At present,China has gained some experience in the development and practice of community home medical and nursing integrated services,but overall,it is still in the preliminary exploration stage.The current situation of imbalanced and insufficient development of community home care integrated services has not changed,and so far,a mature,replicable,and scalable application model that can meet current needs has not been formed.From the existing research,there is a lack of a rational interpretation of the integration of community home care and medical care services,a lack of in-depth exploration of the theoretical basis and corresponding practical mechanisms of community home care and medical care services,and a failure to systematically sort out,summarize,and extract the experience gained in the development process of community home care and medical care services in China based on the practical model of community home care and medical care integration services,And construct a scientific evaluation index system to comprehensively evaluate the practical mode,further optimize the mode and test the implementation effect,in order to select typical and replicable mature community home care integrated service practice modes with Chinese practical characteristics that can be promoted and replicated,taking into account theoretical significance and practical characteristics.Therefore,on the basis of expanding the theoretical analysis framework of "embeddedness" proposed by Karl Polanyi to interpret the cross sectoral collaboration mechanism,this paper integrates the theoretical connotation of collaboration theory,healthy aging theory and social Ecological systems theory,and takes "model classification comprehensive evaluation model optimization effect test" as the research logic thread,A systematic analysis framework of "embedded classification,comprehensive evaluation,mode optimization,and effect analysis" for the practical model of community home care integrated services in China has been proposed.The aim is to comprehensively evaluate and analyze the system,case analysis,qualitative analysis,empirical analysis,and combine field research,interviews,and other methods to analyze and extract the optimal mode of community home care integrated services in China,and further test the implementation effect of the optimal mode,To form a continuous and in-depth study from the theoretical to practical level,providing theoretical guidance and decision-making reference for further summarizing,optimizing,and promoting a community based home care integrated service model that is more in line with China’s current needs.Specifically,it includes the following aspects:Firstly,based on the phased characteristics of population aging development and the severe situation faced by the intensification of aging,and based on the current development status of integrated medical and elderly care services in China and the characteristics of community home-based elderly care services,the necessity,development process,and existing problems of community home-based medical and elderly care services in China were analyzed.Based on a review and sorting of domestic and foreign literature,the research significance of this article was clarified Research ideas and methods.Secondly,the core concepts of this article are elaborated from three perspectives:elderly care services,integrated medical care services,and community home-based elderly care.Based on the theoretical perspectives of healthy aging theory,new public service theory,embedding theory,and collaborative theory,the theoretical logic,theoretical connotation,and corresponding practical mechanisms of community homebased medical care integrated services are systematically elaborated,And based on the research logic of "pattern classification comprehensive evaluation mode optimization effect testing",a theoretical analysis framework of "embedded classification comprehensive evaluation mode optimization effect analysis" for the practical model of community home care and medical care in China was constructed,providing theoretical support for subsequent research.Thirdly,an analysis was conducted on the current situation of community home care integration services in China from the aspects of development,pilot projects,establishment,practical practices,service enjoyment and willingness.The main problems that urgently need to be solved in practice of community home care integration services in China were summarized.Further,using the practice cases in the "Best Practice of Combination of Medical Care and Nursing Care in China" jointly carried out by the National Health Commission and the World Health Organization in2019,a simple analytical framework of "two-way collaborative embedding" was proposed and constructed based on the embedding theory,and Grounded theory was used to try to analyze the general characteristics of the theoretical level of the practice model of combination of medical care and nursing care at home in communities,The paper summarizes the classification of practice models of community home-based care services in China,that is,the "integration and embedding model of community homebased care services",the "integration and embedding model of community grassroots medical and health services" and the "Internet plus+integration of medical care and elderly care" platform integration and embedding model.Fourthly,a three-dimensional evaluation and analysis framework of "whole system subjective" is proposed.From the perspective of the overall environmental effect of the practice model,the "input output" efficiency and the subjective evaluation of the model,the three types of community home based medical care integration service practice models are comprehensively and systematically evaluated using the community home based medical care integration service environment evaluation index model,DEA Malmquist index model and AHP Delphi method method.Research has found that the trend of environmental development index changes in the integrated embedding model of community grassroots medical and health services is significantly higher than that of the integrated embedding model of community home-based elderly care services;From the analysis results of DEA Malmquist index model,the rising trend of Total factor productivity of the integration and embedding model of community home-based medical services is more obvious than that of the integration and embedding model of community home-based elderly care services,and it also shows this feature in the regression analysis results;After using AHP Delphi method method to analyze,it is found that the community grassroots medical and health service integration and embedding model has better practice effect than the community elderly care service integration and embedding model,while the "Internet plus+medical and nursing" platform integration and embedding model takes into account the practical characteristics of community home elderly care service embedding and community grassroots medical service embedding.Fifthly,according to the evaluation research results and combined with the firsthand data obtained from the field survey,the paper proposes and constructs the operation mechanism analysis model(SQ-SES)of the community home care service practice model based on the social Ecological systems theory,and deeply analyzes the core subsystems of the three types of practice models in the resource system(RS),resource unit(RU),governance system and actor(A)and the operation mechanism between them,And conduct practical path restoration,analysis,and comparison.Research has found that the integration and embedding model of community grassroots medical and health services exhibits a characteristic of "bidirectional embedding" in the collaborative process.Not only can community medical and nursing service institutions provide professional grassroots medical and nursing services(such as family doctor signing,family bed,chronic disease management,bidirectional referral,etc.)to daytime care,community elderly care service institutions,or elderly people in home communities through institutional contracts,Community grassroots medical service institutions can also establish internal elderly care service institutions/beds to provide more diversified medical care services for the elderly in need.This practical measure breaks the drawbacks and shortcomings of other single practice models.This model has good resource endowment and reflects good results in the comprehensive evaluation of the model.The efficiency of the practical model is significantly better than other models,and the analysis results are significant both at the resource supply level and the subjective evaluation level.Sixth,from the background of China’s population aging,healthy aging,changes in family structure and high-quality development of elderly care services,based on the theory of healthy aging,using the China Health and Retirement Longitudinal Study(CHARLS)2011,2013,2015 and 2018 Panel data,based on the 2016 national level pilot of integrated medical and nursing services as a quasi Natural experiment,We empirically tested the implementation effect of the optimal selection model(community grassroots medical and health service integration embedded model)using the double difference method(DID).Specifically,while considering its heterogeneity characteristics and corresponding practical mechanisms,the focus is on demonstrating the actual impact of practical models on elderly individuals(physical function,health self-evaluation,mental depression level),health and medical service utilization(primary care,total medical expenditure,personal medical expenditure),and intergenerational care(probability of child care,indirect care expenditure)at the micro individual utility level,Furthermore,regional heterogeneity was further demonstrated,and on this basis,empirical tests were conducted to compare the effectiveness differences brought by the other two practical models at the individual and intergenerational levels,with the aim of comprehensively and systematically evaluating the implementation effectiveness,impact mechanism,and macro level impact of the optimal selection model.Unlike existing literature,this article focuses on the research of the practical mode of community home medical and nursing integrated services in China.Based on indepth analysis of the behavioral logic and practical mechanism of the main body of community home medical and nursing integrated services,a problem oriented research centered on "problem interpretation,experience induction,mode evaluation,and effect analysis" is implemented,expanding the theoretical and logical connotation of the collaborative process of community home medical and nursing integrated services,And it breaks the limitations of existing literature in terms of research perspectives,research methods,material data acquisition,and policy recommendations,and overall enriches the practical research of the integration of medical and nursing care.Compared with existing literature,the marginal contribution of this article lies in the fact that,from a research perspective,typical cases released by the Health Commission in collaboration with the World Health Organization,as well as on-site research and interview data conducted by the research group,can be used as first-hand data materials to systematically and comprehensively reflect the overall situation of community home care integration services in China at present,breaking the fragmentation,modular regionalization,and one-sided perspective of academic research on medical care integration;In terms of research methods,based on interdisciplinary collaboration,it realizes the interaction and collaboration between research methods,and comprehensively uses quantitative research,qualitative analysis,Field research,case analysis and other research methods to comprehensively and comprehensively evaluate the implementation effect of the practice model of home based medical care services in China from point to surface;Summarize and refine the model optimization path that is more in line with China’s practical characteristics at the current stage in the conclusion,forming a continuous in-depth study from the theoretical to practical level,providing theoretical guidance and decision-making reference for improving and optimizing the development of China’s community home medical and nursing integrated service model.Based on the above research,this article proposes the following suggestions: firstly,further expand the integrated embedding model of community grassroots medical and health services for the overall embedding effect in community home care integrated services,streamline its resource integration logic and service supply logic,establish and consolidate the core role of community grassroots medical and health integrated embedding model in community home care integrated services,Further grasp the respective advantages of the two practice modes of community grassroots elderly care service integration embedded mode and "Internet plus+medical care" platform integration service.On the basis of enriching their embedded forms,actively use the Internet integration platform to realize the cooperation mechanism between practice modes and the transformation of different service groups.Further,optimize the resource integration logic and service precision supply logic of the community’s home based medical and nursing integrated service resource supply end,and improve the matching degree between the optimized model and elderly people of different demand levels on the basis of the existing model,to achieve precise supply of community home based medical and nursing integrated services;Secondly,it is necessary to further refine and classify the service mode of combination of medical care and nursing care at home in the community.Starting with the main Logical framework of the service mode of combination of medical care and nursing care at home in the community,it is necessary to further refine the three sub modes of "tight","loose" and "intermediate" on the existing preferred mode,and strengthen the policies,funds The construction of hardware equipment and other support systems,as well as the consolidation and establishment of a dynamic collaborative mechanism for optimizing,refining,and promoting the practical model of community home care and medical care integration services.In the future,more attention should be paid to the supply scope and demand level of community home-based medical and nursing integrated services.On the basis of achieving wide coverage,further efforts should be made to achieve multi-level and cross regional coverage of community home-based medical and nursing integrated services from the perspective of model classification,pay attention to the comprehensive trend of population aging,dynamically adjust the matching mechanism between elderly people with different health levels’ needs and practical models,and achieve the integration of medical and nursing integrated services with population structure The combination of changes in family structure and other external factors has incorporated the optimization,development,and practice of the integrated medical and elderly care service model into the long-term task of elderly care services and population aging,continuously improving the comprehensive development and service capabilities of the integrated medical and elderly care service,and effectively playing a role in actively responding to population aging.更多还原