Development of a senior-specific, citizen-oriented healthcare service system in South Korea based on the Canadian 48/6 model of care

Aging is a victory for human development. Life extension is one of the greatest achievements of humankind. As standards in nutrition, hygiene, medicine, healthcare, education, and economic life have improved, the longevity of people has become possible [1]. According to United Nations’ 2015 Revision of the World Population Prospects, the number of people aged 60 years or older will increase rapidly over the next few decades, and the rate of increase will continue to accelerate. Worldwide, the population of those aged 60 years or older is estimated to increase from 901 million in 2015 to about 1.4 billion in 2030 (a 56% increase) and 2.1 billion in 2050 [1]. In Korea, 39% of the population will be aged 60 years or older by 2050 [1]. The life expectancy of Korean women who will be born in 2030 is estimated to be 90.82 years [2]. A serious consequence of population aging is the increase in occurrence of chronic diseases [3], which already account for 60% of deaths worldwide, as well as half of the deaths due to disability [3]. Chronic diseases are the overwhelming causes of disability and death, regardless of income and age [1, 3, 4].

As the elderly population increases, the primary focus is to reduce the gap between life expectancy and healthy life expectancy, the latter being defined as the average expected years of life in a healthy condition for persons at a given age [5].

Korea has a life expectancy of 82.16 years [6], whereas its healthy life expectancy is 73.2 years [7], indicating that the average unhealthy life period lasts about 10 years. This phenomenon gave rise to the proverb “9,988,234” in Korea, which means that you live to be 99 years old (99) by having a healthy life (88), but fall sick for only 2 or 3 days and then die (234). If people live with a disability for the duration of their extended life expectancy, the demand for medical care will increase.

Therefore, the government of the Republic of Korea has been implementing various policies to maximally promote the health and welfare of the elderly, including: (1) visiting home healthcare services for health risk groups; (2) campaigning for healthy life practices to prevent and control chronic diseases, such as lowering sodium intake; (3) operating “100-year-old health athletic classrooms” in highly accessible spaces, such as senior centers, parks, and school playgrounds, as well as elderly exercise voucher projects; and (4) early dementia screening and treatment management support [8]. However, as elderly people have different health and welfare needs, the proportion of total healthcare insurance expenditures represented by the costs of providing elderly medical care has continued to increase, rising from 32.2% in 2010 to 38.7% in 2016 [9].

Korea’s healthcare delivery system allows patients free choice of hospital due to the absence of a control mechanism. In terms of medical institutions, the system is divided into the first stage (clinic and general hospital) and second stage (tertiary hospital). Patients who can be adequately treated at first-stage medical institutions can freely use second-stage medical resources [10].

Primary healthcare, the backbone of the healthcare delivery system, has shrunk significantly over the last decade; it now constitutes only half of Korea’s entire healthcare coverage. This collapse in the healthcare delivery system has hindered the provision of integrated and cost-effective healthcare services by increasing the burden on the public and undermining relations between doctors and patients. As clinics and tertiary hospitals compete for outpatients, the number of patients in tertiary hospitals is growing so rapidly that it reduces quality time between physician and patient. At the same time, this defect in the healthcare delivery system has led to large-scale patient infections in several large hospitals, including a general hospital [11]. Moreover, Korea’s healthcare delivery system fails to ensure post-acute care facilities to provide community-based or general hospital transition care services.

The National Health Insurance Service has emphasized the need to change the healthcare system into one centered on the community: “If we maintain the same hospital-centered medical system in the age of aging, we will face problems such as medical refugees and caring refugees because the management of medical expenses becomes impossible” [9]. Korean hospitals have been unable to grasp the needs of the elderly when providing disease-centered care; healthcare delivery has operated as a one-way system focused on the provider, rather than on the elderly as the user. However, community-based healthcare systems cannot prevent disease occurrence or progression unless they understand the needs of the elderly.

Recently, the concept of “citizen oriented” has been introduced in Korea as a framework for providing customized services. Studies on citizen-oriented endeavors have been conducted mainly in the areas of information and communication technology [12‐14]. In science and technology, “citizen oriented” has been defined as “science and technology to meet the daily life needs of the people and improve the quality of life, such as health, safety, welfare, and improvement of life inconvenience” [15]. In other words, ‘citizen oriented’ refers to services (e.g. medical services, information and communication technology, wearable devices, etc.) that people can use in everyday life without discomfort.

This study defines senior specific, citizen-oriented healthcare as a service system that can achieve well-being, wellness, and well-dying by organizing daily care, professional care, and rehabilitation between medical institutions and local communities, as well as satisfying the daily life needs of the elderly in health, safety, welfare, and living. This means that the elderly can be engaged in well-being, wellness, and well-dying if they are provided with medical services that meet their needs where they are located (e.g. hospital, nursing home, community-dwelling, home care, etc.). In this study, well-being, wellness, and well-dying have been defined as follows. Well-being indicated improving life quality and happiness by maintaining self-care and normal physical functioning for daily needs through life-friendly senior healthcare services. Wellness implied health improvement through a personalized healthcare program for the elderly who are able to function independently in their daily care, professional care, and rehabilitation stages, as well as for the elderly who are partially able to provide their own care and those who need assistance. Well-dying referred to ending life happily and beautifully by minimizing the possibility of accidental death caused by increasing bodily deterioration.

People have various social and medical needs in their everyday life, and fulfilling these needs is the starting point for improving quality of life. Improving the quality of life of the elderly is thought to slow down biological, social, and functional ageing and provide active, healthy, and successful ageing. Additionally, if the healthy life expectancy of the elderly can be increased, thereby reducing the period of disease occurrence, then medical expenses related to increased life expectancy may be reduced. Thus, this study attempts to contribute to gerontology and geriatrics by developing a senior-specific, citizen-oriented healthcare service system based on Canada’s 48/6 Model of Care for Well-being, Wellness, and Well-dying.

This study established a senior-friendly hospital (SFH) working group for the development of a senior-specific, citizen-oriented healthcare service system. The SFH working group comprised experts from Konkuk University and Konkuk University Hospital specializing in various fields: clinicians (neurology, rehabilitation medicine, respiratory allergy medicine, psychiatry, head and neck otolaryngology, and family medicine); preventive medicine doctors; nurses from mostly elderly wards, dieticians; pharmacists; and a quality improvement facilitator.

In addition, an external expert group was formed to further review the development of a senior-specific, citizen-oriented healthcare service system, comprising professors of urology and surgery, geriatric specialists, elderly drug experts, health administration practitioners, geriatric nurses, community nurses, and health center directors.

As shown in Fig. 1, the SFH working group conducted a systematic review and a literature review and benchmarked Canada during the development of a ‘senior-specific, citizen-oriented healthcare service system’. A member of the SFH working group was the moderator for the focus group interviews.

Based on Canada’s 48/6 Model of Care, the following senior-specific, citizen-oriented healthcare service system is proposed (Fig. 3).

According to the Korean Medical Law, primary medical institutions, such as medical clinics, serve as gatekeepers for healthcare systems, responsible for the prevention of disease, continuous healthcare, and strengthening of community health. The hospitals are equipped with a medical delivery system for intensive treatment of severe and emergency patients [71, 72]. However, in reality, the medical delivery system is not completely settled, and owing to the competition between general hospitals and clinics over outpatients, patients do not have adequate access to subacute hospital care, primary care, home care, and long-term care after acute care.

Moreover, when patients and/or caregivers require care transition (subacute hospital care, primary care, home care, and long-term care), their current hospital may provide limited information. Consequently, the continuity of medical treatment is disrupted because the care transition plan is not established and evaluated.

This study developed a senior-specific, citizen-oriented healthcare service system, based on the need to establish and manage treatment plans for patients using standardized screening tools. These tools can be used to check for concerns after discharge, and whether the patient chooses to receive ongoing care in a sub-acute hospital, community-based rehabilitation facility, local nursing facility, their family or caregiver’s home, or their own home.

In contrast to the Canadian 48/6 Model of Care [63, 64], the proposed senior-specific, citizen-oriented healthcare service system can provide screening within 24 h to establish a treatment plan. The system applies the Korea Institute of Healthcare Accreditation’s standards for assessing a patient’s condition within 24 h and establishing a treatment and discharge plan [73]. In addition, while the Canadian 48/6 Model of Care [63, 64] comprises six domains (bowel and bladder management, cognitive functioning, functional mobility, medication management, nutrition and hydration, and pain management), the proposed system for Korea comprises 10 domains (cognitive impairment, depression, delirium, polypharmacy, functional decline, dysphagia, malnutrition, urinary incontinence, fecal incontinence, and pain). The SFH working group re-categorized the Canadian domains of bowel and bladder management and cognitive functioning (delirium, depression, dementia), which are regarded as the important physical and mental state changes of the elderly. In the 48/6 Model of Care, dysphagia is included in nutrition and hydration; however, the SFH working group classified dysphagia as an individual domain by regarding it as an important factor in pneumonia and malnutrition. In contrast to the currently used Korean IADL Scale [74] and the Korean Comprehensive Assessment Tools for geriatric ambulatory care [75], the GSC-10 is not limited to any particular assessor (medical team, staff, caregiver, self-report), healthcare setting (acute, long term, community dwelling, or home care), or within-hospital setting (outpatient, inpatient, emergency department).

In Canada, with central government support, each provincial government is responsible for healthcare provision, as well as the operation of its own health insurance plan; all health services are provided to all residents by hospitals, practitioners, dentists, and other medical professionals [76]. In addition, Canada has a cooperative system between community resources for patient transfer or referral, allowing for continuous management after discharge [66]. Korea lacks such a medical delivery system, attributed to reasons such as the shift of patients to large hospitals, excessive input of unnecessarily expensive medical equipment, excessive competition, and polarization of medical institutions. Competition among medical institutions is a costly and wasteful aspect that places importance on reputation, causing qualitative polarization among medical institutions. Consequently, the consumer faces the difficulty of choosing the appropriate medical institution themselves, and ultimately receives segmental, temporary, and fractional services [77]. In 2016, the Ministry of Health and Welfare carried out a pilot project for the transfer or referral of patients between medical institutions to improve the medical delivery system. However, their efforts were limited to improving the delivery system between medical institutions.

When a healthy elderly person is admitted to a medical institution, their psychological and physical condition may not be restored or may even worsen in a system that restricts independent activities [66]. A 2011 report indicated that approximately 30 to 40% of elderly patients lose the ability to perform at least one of their daily activities within 2 days of hospitalization [78]. Meanwhile, about 13% of hospitalized elderly patients die within 1 year of hospital discharge [79]. These facts highlight the importance of not only hospitalization but also continuing care after discharge.

The senior-specific, citizen-oriented healthcare service system was developed to enable continuous management by establishing cooperation between community resources after discharge, as well as during hospitalization. The present healthcare service system applies a medical delivery system to the care transition management between a public health center in the community (subacute hospital care, primary care, home care, and long-term care) and a tertiary hospital to ensure appropriate care transition patient management.

The most important concern for the elderly is to be able to live healthily and independently for the rest of their lives through well-being, wellness, and well-dying.

The senior-specific, citizen-oriented healthcare service proposed in this study uses an integrated medical treatment system for elderly users. It enables the establishment of patient-specific treatment plans and appropriate intervention through the screening and evaluation of 10 items that organically influence elderly health. The 10 areas are screened not only on admission but also during hospitalization and even after discharge, with an aim of monitoring the health of the elderly patient by observing identified problems even after discharge. In addition, this system enables the prompt diagnosis and treatment of diseases that are common to the elderly through a multidisciplinary treatment plan that can be considered by the patient and their family members. Regarding the issue of the elderly facing heavy social and economic burdens due to aging, one solution is to establish a systematic patient linkage system between medical institutions and community resources.

Since the physician surcharge was abolished in 2018, Korea has seen the proliferation of large hospitals, and its medical delivery system is characterized by clinics and tertiary hospitals competing for outpatients. The government is examining a variety of medical delivery systems, such as a community-based transfer or referral system that can provide appropriate treatments to patients according to the type of medical institution. This study developed the GSC-10, which can be applied in all medical institutions, and an evaluation tool for medical institution-based usage. To facilitate implementation, we also proposed a management method for each item, and presented a model to ensure continuous care for the elderly even after moving to other medical institutions or back into the community.

If the government were to extensively implement the senior-specific, citizen-oriented healthcare service system proposed in this study, the daily care, professional care, and rehabilitation of elderly members of society would be organically organized according to the role of the patient, family members, and the caregiver, ultimately improving well-being, wellness, and well-dying in the elderly.