Shanghai Integration Model
The Shanghai Integration Model:
A Three-Year Public Health Action Plan and a Platform for Peer Support
Diabetes challenges integration across both dimensions of care (medications, specialty services, self management, etc.) as well as contributors to care (specialists, primary care providers, nurses, dietitians, patient educators, family and friends, and individuals with diabetes). To achieve both of these, the Shanghai Integration Model (SIM) links well organized specialty care with primary care through Community Health Centers (CHCs) in the neighborhoods in which people live. Representatives from CHCs, tertiary hospitals, and municipal government health agencies developed a working strategy emphasizing community based health promotion for risk factor control, early detection, health management, and complication screening and disease/case management.
A city-wide prevention and treatment center at the Shanghai Sixth People’s Hospital provides guidance to the project, training, and subspecialty treatment of difficult or intractable cases. A comprehensive information management platform supports remote technology for retinopathy screening and monitors/guides algorithm-based integration of care and referrals both from CHCs to hospital/subspecialty care and back to CHCs for ongoing care. In 2015, the Shanghai Municipal Government initiated a large project for diabetes as part of the three-year action plan for strengthening the public health system in Shanghai. The major components of this three-year plan are being rolled out through the SIM.
The SIM is directed by Professor Weiping Jia, President of the Shanghai Sixth People’s Hospital and of the Chinese Diabetes Society and an international expert of diabetes and its care. Professor Jia is responsible for the overall design, implementation and evaluation of the SIM. From the Shanghai Municipal Government and the Shanghai Health Bureau, Director Chun Cai directs the project administration and coordinates among stakeholder organizations.
- With Shanghai’s 24 million population, the objectives of the three-year public health and its initial progress include: Training of medical staff from all 240 CHCs, each serving an average 100,000 residents, to improve prevention and routine diabetes care – 1531 staff trained to date
- Standardization of laboratory tests for fasting glucose, hemoglobin A1c, and urine albumin-to-creatinine ratio (UACR) – CHC labs conducting UACR increased from 5 to 148
- Screening 300,000 at high risk for diabetes – 154,100 screened through 195 of 240 CHCs, identifying 16,716 with diabetes and 20,333 with prediabetes
- Screening 250,000 with diabetes for peripheral neuropathy, lower extremity atherosclerosis, nephropathy, and retinopathy – to date close to 60,000 screened through the CHCs
The Shanghai Integration Model as a Platform for Peer Support
The coordination of specialty/hospital care with primary care through CHCs does not itself guarantee improved outcomes. Realizing the benefits of integrated care requires patient engagement in care and daily self management. In evaluation of diabetes care through CHCs, staff reported that only 30-40% of patients practice self management behaviors that staff see as leading to better glucose control. They attributed this to a lack of knowledge or misunderstanding about medication use (e.g., not knowing when to take medications; terminating medication when glucose control is good) and also lack of knowledge about healthy diet, calories and food types. They also described psychosocial and diabetes-specific distress or indifference about diabetes as compromising individual care and quality of life. Especially among older adults, there is often difficulty sustaining physical activity.
Peer support through nonprofessional, volunteer Coaches from the neighborhoods CHCs serve can address these problems. In collaboration with Peers for Progress, staff and Coaches from ten of Shanghai’s 240 CHCs advised on the development of a peer support program to help patients take full use of care through the SIM and to carry out in their daily self management tasks critical to good diabetes management. Depending on each CHC’s capacity to recruit qualified personnel, Coaches can be either individuals with lived experience of diabetes or community leaders that are engaged in public health promotion. Training for Coaches emphasizes:
- The principal role of Coaches as not didactic educators but collaborators with individuals in enhancing engagement in care and self management
- The fundamental value of a supportive relationship with a Coach
- Coaches’ role as more like friends than teachers
- The importance of social and emotional support
- Acceptance of the gradual nature of behavior change
Throughout the trainings, Peers for Progress continues to emphasize that the effectiveness of Coaches does not lie in their medical expertise or being the “best” patients. Instead, Coaches are more effective when they model coping with the challenges of diabetes management; that is, sharing their experiential knowledge of day-to-day life with diabetes. Objectives for quality improvement include identifying and addressing various determinants of individual self management, improving training effectiveness to ensure proficiency in communication and support skills, and promoting practical ways to better manage Coaches and integrate them in CHCs. In parallel, this project will explore avenues for extending Coach services to diabetes prevention in high risk groups and support for newly diagnosed individuals. Following prototype development and evaluation in ten initial CHCs, dissemination will extend to all 240 Shanghai CHCs.
An extension of Coach program is designed to help those who are prescribed insulin to adapt and adhere to this component of their diabetes care. This began by evaluating circumstances surrounding insulin therapy in CHCs and the potential role of Coaches in promoting insulin therapy. Clinic records and interviews with staff and patients revealed that most people with diabetes use only oral medication and under-utilize insulin. Interviews revealed a variety of barriers, including lack of insulin knowledge, worry that once insulin is begun it cannot be terminated, availability of insulin in CHCs, economic burden of insulin needles, inconvenience especially among older adults with compromised vision or hand steadiness, reluctance to use insulin in public areas, and worry about hypoglycemia, weight gain or needle pain.
Peer Coaches can address these barriers to valuable insulin care.
Attitudes: Clinical staff may communicate the value of insulin therapy but peer support from someone “like me” is especially credible in changing concerns about “what will this be like for me?”
Economic burden: Peer Coaches can help individuals solve concrete problems including finding less expensive ways to follow a routine.
Knowledge: Coaches may supplement clinic education by troubleshooting and rehearsing proper insulin use.
Older patients: Properly trained, coaches have time to spend with those who need extra help in learning to manage insulin. This can include making home visits until an individual is able to safely and effectively use insulin.
Protocols for Coaches have been developed with CHCs and the Shanghai 6th People’s Hospital staff. Coaches and staff from ten CHCs have completed training, to be followed by ongoing consultation to enhance program implementation and quality improvement. Stepped wedge evaluation from these ten will guide subsequent dissemination to all 240 CHCs in Shanghai.
Professor Jia’s leadership in establishing the Shanghai Integration Model has created the conditions for high quality, coordinated diabetes care across the city. In addition, the model provides a strong organizational base for implementing and delivering peer support. The added value of peer support to the Shanghai Integration Model is improved patient engagement in care, advancement toward collaborative care, greater utilization of CHC-based primary care, and stronger integration between primary and specialty care. By building the case for peer support and integrated care in Shanghai, this project hopes to encourage leaders in China to adopt similar approaches for better diabetes care across the country.