Wang et al:The Luohu Model Art.3,page5 of 10 health stations and became members of family doctor collaboration between district hospitals and community teams.Health care delivery for patients with chronic health stations promoted patient referral in the hospital diseases changed from treatment-dominated to preven- group.No patient was referred from hospitals to commu- tion-first based on three strategies. nity health stations for follow-up or rehabilitation services First,the group paid more attention to preventive care. in 2015,but in 2016 over 10,000 patients were referred For example,regular lectures were given in each commu- from hospitals in the group to community health stations nity and a Healthy Luohu app was designed for improving to receive the right care at the right place. residents'health literacy.In cooperation with the govern- Outcome evaluation.During the past two years,4,596 ment,the group helped to construct two jogging trails for more patients with diabetes,4,995 more patients with residents,to cultivate exercise.Moreover,free pneumonia hypertension and 822 more patients with severe mental vaccinations were provided for those over 60 years of age illness were enrolled in case management (Table 1). in2016. Compared with Jun 2014-Dec 2015,there were more new Second,the group introduced screening programs for cancer cases per month identified during Jun 2015-Jun diseases with high morbidity and mortality,with particu- 2016.There was a decrease in pneumonia cases in the lar focus on cancers.Screening programs for breast cancer, second year after reform.Residents'satisfaction with com- cervical cancer,lung cancer,liver cancer,and gastrointes- munity health stations in Luohu ranked first among the tinal cancer were introduced [24],to support early diag- ten districts of Shenzhen in 2015 and 2016.However,the nosis and treatment. mean cost per resident of all types of health care increased Third,physicians prepared individualized healthcare fom$675.3to$844.2. plans for patients and provided medical treatment and non-drug guidance regularly in collaboration with general Discussion practitioners.There is a Referral Gateway between general Stakeholders pushing the reform practitioners in community health stations and hospi- The District government of Luohu gave priority to health, tals in the group.Whenever patients need the services and set the direction for the reform by 'shifting focus from of specialists,physicians will refer them to one of the treatment to health".The District government helped the group's hospitals and continue to follow up. District Health and Family Planning Commission to coor- dinate with the Ministry of Finance,Human Resources and Evaluation of the Luohu model Social Security Bureau and Social Insurance Fund Admin- Framework istration,to ensure that supporting measures would be in Devers and colleagues [31]suggested that healthcare place.Further,the District government increased financial integration be evaluated in three dimensions:readiness subsidies to the group,especially community health sta- of integration(structure),internal process of integration tions.In 2016,the Ministry of Finance invested $112 mil- (process),and outcomes of integration (outcome).Selec- lion (accounting for 27.2%of all health expenditures in tion of the second-and third-level indicators was based the district)in the group. on a review of the literature,as well as on the aims of and Staff in the group contributed efforts to the reform. programs in the Luohu model.In this study,we adopted Physicians and nurses adopted a philosophy of serving six indicators to evaluate "structure",eight indicators patients,improving treatment capacity,and strengthen- system to evaluate "process"and 12 indicators to evaluate ing collaboration with team members.Meanwhile,the outcome"(Table 1). reform of salary payments enhanced the enthusiasm of all staff in the group. Results of evaluation Along with staff in the hospital group,residents helped Structure evaluation.In respect of infrastructure,the busi- create and share processes and outcomes of the reform. ness area of community health stations increased from Only by placing residents at the center of the system could 410m2 in Jun 2015 to 903m2 in Jun 2017.The assets the hospital group set the goal of constructing an inte- value of equipment across all community health stations grated care system.Before the reform,patients regarded increased from $2.73 million in Jun 2015 to $4.04 million the community health station as the last choice for service in Jun 2017.The number of general practitioner doubled. because they did not trust the quality of services available The number of public health physician increased from there.Now,42.6%residents regard community health sta- 2 to 30,while 49 specialists set up clinics in community tions as the first contact for health care.Overall,demands health stations,and 238 family doctor teams were devel- of residents have been driving the reform. oped during the same period. Process evaluation.By June 2017,580,000 residents had Strategies for integrated care been registered with general practitioners in the hospi- Some European projects have suggested that organizational tal group.The proportion of all hospitalizations going integration alone is unlikely to deliver better outcomes, to the group hospitals increased,which reduced the cost and that efforts must focus on clinical and service integra- of health insurance in the whole hospital group.In the tion.Other researchers have suggested that effective care group.The proportion of outpatient visits in community coordination can be achieved without the need for the for- health stations increase from 29.49%to 42.60%.This is a mal integration of organizations [32,33].Different from promising indicator that community health stations are most international experience,most pilot programs [34, acting for gatekeeper of the hospital group.Meanwhile, 35 in China mostly began with organizational integration,Wang et al: The Luohu Model Art. 3, page 5 of 10 health stations and became members of family doctor teams. Health care delivery for patients with chronic diseases changed from treatment-dominated to preven￾tion-first based on three strategies. First, the group paid more attention to preventive care. For example, regular lectures were given in each commu￾nity and a Healthy Luohu app was designed for improving residents’ health literacy. In cooperation with the govern￾ment, the group helped to construct two jogging trails for residents, to cultivate exercise. Moreover, free pneumonia vaccinations were provided for those over 60 years of age in 2016. Second, the group introduced screening programs for diseases with high morbidity and mortality, with particu￾lar focus on cancers. Screening programs for breast cancer, cervical cancer, lung cancer, liver cancer, and gastrointes￾tinal cancer were introduced [24], to support early diag￾nosis and treatment. Third, physicians prepared individualized healthcare plans for patients and provided medical treatment and non-drug guidance regularly in collaboration with general practitioners. There is a Referral Gateway between general practitioners in community health stations and hospi￾tals in the group. Whenever patients need the services of specialists, physicians will refer them to one of the group’s hospitals and continue to follow up. Evaluation of the Luohu model Framework Devers and colleagues [31] suggested that healthcare integration be evaluated in three dimensions: readiness of integration (structure), internal process of integration (process), and outcomes of integration (outcome). Selec￾tion of the second- and third-level indicators was based on a review of the literature, as well as on the aims of and programs in the Luohu model. In this study, we adopted six indicators to evaluate “structure”, eight indicators system to evaluate “process” and 12 indicators to evaluate “outcome” (Table 1). Results of evaluation Structure evaluation. In respect of infrastructure, the busi￾ness area of community health stations increased from 410m2 in Jun 2015 to 903m2 in Jun 2017. The assets value of equipment across all community health stations increased from $2.73 million in Jun 2015 to $4.04 million in Jun 2017. The number of general practitioner doubled. The number of public health physician increased from 2 to 30, while 49 specialists set up clinics in community health stations, and 238 family doctor teams were devel￾oped during the same period. Process evaluation. By June 2017, 580,000 residents had been registered with general practitioners in the hospi￾tal group. The proportion of all hospitalizations going to the group hospitals increased, which reduced the cost of health insurance in the whole hospital group. In the group. The proportion of outpatient visits in community health stations increase from 29.49% to 42.60%. This is a promising indicator that community health stations are acting for gatekeeper of the hospital group. Meanwhile, collaboration between district hospitals and community health stations promoted patient referral in the hospital group. No patient was referred from hospitals to commu￾nity health stations for follow-up or rehabilitation services in 2015, but in 2016 over 10,000 patients were referred from hospitals in the group to community health stations to receive the right care at the right place. Outcome evaluation. During the past two years, 4,596 more patients with diabetes, 4,995 more patients with hypertension and 822 more patients with severe mental illness were enrolled in case management (Table 1). Compared with Jun 2014–Dec 2015, there were more new cancer cases per month identified during Jun 2015–Jun 2016. There was a decrease in pneumonia cases in the second year after reform. Residents’ satisfaction with com￾munity health stations in Luohu ranked first among the ten districts of Shenzhen in 2015 and 2016. However, the mean cost per resident of all types of health care increased from $675.3 to $844.2. Discussion Stakeholders pushing the reform The District government of Luohu gave priority to health, and set the direction for the reform by “shifting focus from treatment to health”. The District government helped the District Health and Family Planning Commission to coor￾dinate with the Ministry of Finance, Human Resources and Social Security Bureau and Social Insurance Fund Admin￾istration, to ensure that supporting measures would be in place. Further, the District government increased financial subsidies to the group, especially community health sta￾tions. In 2016, the Ministry of Finance invested $112 mil￾lion (accounting for 27.2% of all health expenditures in the district) in the group. Staff in the group contributed efforts to the reform. Physicians and nurses adopted a philosophy of serving patients, improving treatment capacity, and strengthen￾ing collaboration with team members. Meanwhile, the reform of salary payments enhanced the enthusiasm of all staff in the group. Along with staff in the hospital group, residents helped create and share processes and outcomes of the reform. Only by placing residents at the center of the system could the hospital group set the goal of constructing an inte￾grated care system. Before the reform, patients regarded the community health station as the last choice for service, because they did not trust the quality of services available there. Now, 42.6% residents regard community health sta￾tions as the first contact for health care. Overall, demands of residents have been driving the reform. Strategies for integrated care Some European projects have suggested that organizational integration alone is unlikely to deliver better outcomes, and that efforts must focus on clinical and service integra￾tion. Other researchers have suggested that effective care coordination can be achieved without the need for the for￾mal integration of organizations [32, 33]. Different from most international experience, most pilot programs [34, 35] in China mostly began with organizational integration