New program brings nurses to the doorsteps of the elderly
In-home nursing services, long a gray area of the senior healthcare system, has received authorization from the National Health Commission in a decision that has drawn initial praise from the medical community and many elderly patients.
A notification released in mid-February creates a trial program allowing people to make home appointments via app or Internet for nursing services in the cities of Shanghai, Beijing, Tianjin and in the provinces of Jiangsu, Zhejiang and Guangdong.
The trial will run through December. A number of concerns about the actual operation of the program are still to be resolved.
The program’s in-home services cover chronic disease management, rehabilitation care and palliative care. The primary targets are elderly with disabilities or health problems and those convalescing from hospital treatment or surgery.
Nurses providing the services must have a minimum five years of clinical nursing work experience and certain technical certifications, according to the program criteria.
It also contains measures to protect personal information, authenticate patients, schedule nurses, offer emergency responses, handle disputes and monitor the program’s progress.
The program is being trialed in provinces and municipalities with large and aging populations, said Jiao Yahui, deputy director of the Medical Administration Bureau under the National Health Commission.
"The increasing number of elderly who suffer from physical disabilities, who are at an advanced age and who are living alone has led to surging demand for doorstep nursing services," said Jin Chunlin, director of the Shanghai Health Development Research Center.
Lu Qunfeng, director of the nursing department at the Children's Hospital of Shanghai, said the trial program carries positive prospects.
"The life expectancy of Shanghai residents keeps rising year on year, while the incidence of disease among seniors grows as well,” he said. “An increasing number of senior patients suffer from cancer and other chronic diseases. The policy will bring them greater convenience and help ease some of the burden on their children."
Cheng Yun, director of nursing at Huadong Hospital affiliated to Fudan University, said the program will tackle the difficulties facing seniors.
"Sometimes, children take their elderly relatives to hospitals just to get a catheter changed, which can be easily done by an in-home nurse,” she said.
For many seniors, constant trips to a hospital or clinic for minor procedures is difficult, time-consuming and tiring.
"I visit a community health center to have insulin injections or I do the injections by myself at home," said Chen Lanying, a diabetes patient in her 80s in Hongkou District. "The former is troublesome, and the latter may not be safe if a person can't manage an injection. This new service provides another option, and I will ask my son to make an appointment for me. I hope the price is affordable."
The number of seniors 60 years or older in China topped 240 million by the end of 2017, accounting for 17 percent of the population, according to the National Bureau of Statistics. Among them, 150 million suffered from chronic diseases and about 40 million had physical disabilities.
In Shanghai, that population segment expanded 5.6 percent to 4.8 million in 2017, accounting for a third of permanent residents.
To reduce potential problems, the trial mainly covers treatments with low medical risk and easy procedures such as injections and infusions, according to the health commission notice.
The concept of providing in-home care services is not new in Shanghai. In 2015, a WeChat account called Qianjia Wanhu provided cleaning services for elderly and other people at risk. It took in 50,000 reservations a day in the first year, without any advertising or promotion.
One app offering in-home nursing services
In 2017, some apps appeared for in-home nursing services in Shanghai, Beijing and Guangdong and Fujian provinces. The apps offered services spanning injections, transfusion, blood collection and catheters.
However, the fees were as much as triple those charged by hospitals and clinics, and there were no standards to cover their operation. Shanghai health authorities closed down one app with “irregularities” related to qualification of nurses, operations beyond an allowable scope and poor treatment data.
The new program will technically eliminate the risks and unlawful practices that have occurred with some previous apps.
A Shanghai woman surnamed Wang paid 199 yuan (US$29.46) on a "whitening injection" via an app called Yihu Daojia.
"The nurse didn't even look at the drug information before starting the transfusion," said Wang. "And she didn't show me her nursing accreditation."
The injection required a dilution of 250 millimeters of salt water, but the nurse used only 100ml. She wore no mask and just dropped the used needle in the garbage bin, Wang said.
About 10 minutes after the injection, Wang became nervous, tingling and chilled.
"The nurse didn't take any steps to ease my symptoms after I complained of discomfort," she said.
Wang said she returned to normal after more than two hours and after drinking warm water.
Another nurse who was signed up with an app admitted that she infused patients with chemotherapeutic agents used to treat breast cancer — a procedure not allowed outside of hospitals. Customers were also given treatments to determine the gender of a fetus, which is also illegal.
A Shanghai resident surnamed Yang said he had arranged an appointment via an app to have a nurse change a catheter for his grandmother.
"The nurse had good attitude, but she was not skilled or professional," he said.
If problems or disputes arise from in-home nursing services, mechanisms need to be in place to resolve them.
"There is no surveillance camera to capture the service process, and it is difficult to make a judgment about what occurred," said the Health Development Research Center’s Jin. "Medical treatment institutions should equip nurses with recorders, and the data and materials used during the service process should be recorded for checking and tracing."
Huadong Hospital's Cheng said clear guidelines are needed.
"If accidents happen involving intramuscular injections, intravenous injections or even more complicated operations, the question is how to ensure the safety of patients and nurses," she said.
Guidelines on pricing and payment also must be established, Jin said.
In China, nurses cannot prescribe medicines, and if bleeding occurs, they can't issue prescriptions.
"Authorities must detail service items and make clear the quality and safety of management procedures," said Lu with the Children's Hospital.
Another problem is the short supply of nurses in Shanghai. Some are hesitant to offer services in the home.
"Our personal safety, how to handle treatment disputes and whether we might be subject to theft accusations from working in a private home are big concerns," said a nurse in Shanghai surnamed Zhang.
Experts said most nurses are young women, and guaranteeing their safety when visiting a strange patient's home can be a problem.
The Shanghai Health Commission said it is working on detailed guidelines and implementation rules.
