In recent years, the aging trend has become prominent in China. There was 249 million elderly people more than 60 years old and 167 million elderly people more than 65 years old in 2018, accounting for 17.90% and 11.90% of the total population of the country, respectively, according to the latest statistics of the elderly population released by the National Bureau of Statistics. The proportion of the population aged over 65 years old has been increased year by year, and the old-age dependency ratio has been also increased year by year [1]. The number of people aged more than 60 years old is expected to increase to about 255 million by 2020, accounting for 17.8% of the total population; and the old-age dependency ratio is expected to increase to around 28%; the elderly with venerable age is expected to reach up to 29 million, while the elderly living alone and the empty-nested elderly are expected to reach up to 118 million [2], according to China's "Thirteenth Five-Year Plan" for the Planning of Developing the Aging Industry and Constructing the Endowment System. As the aging trend is accelerating, the numbers of the elderly with venerable age, the disabled elderly, the semi-disabled elderly witness sustain growth in China. There were more than 40 million disabled and semi-disabled elderly people in China by the end of 2016. And 7% of the families should conduct long-term care for the elderly. Those who need direct care also desperately need the involvement of medical service [3-4]. Compared with developed countries in Europe and the United States, China shows a unique aging characteristic of such as getting aging far before becoming wealthy, larger scale, faster speed, and heavier dependency burden, etc. What's more, China's pension security system should be improved. And the Chinese society is encountered with tremendous pressure under the challenge of an ever-increasing aging trend.
With the basic national family planning policy and economic and social transformation, the family supporting function has been weakening, while the elderly’s demands for professional nursing institutions and community services have been steadily on the increase. In particular, the elderly aged over 80 years old with a high morbidity rate of chronic disease desperately needs systematic, comprehensive, convenient, and low-cost medical services. Moreover, both medical and elderly care, as a matter of fact, are indispensable for the disabled and semi-disabled elderly [5]. The elderly’s medical needs cannot be satisfied neither in most of the old-age nursing institutions that provide low-level medical services with few qualified nursing staff and limited beds, nor in medical institutions which cannot provide long-term hospitalization services for the elderly due to their limited resources. Besides, care resources in the community level cannot fully cover the medical and nursing demands of the disabled elderly and the elderly suffering from diseases.
The aging of population has exacerbated the shortage of resources for medical services and elderly nursing, which has put forward a request for improving the allocation and utilization of social resources. The traditional elderly nursing model cannot satisfy the elderly’s all-round care needs. It is imperative to implement health care for the elderly. Nevertheless, medical treatment and elderly-care resources are inadequately supplied and mutually independent, which cannot meet the needs among the elderly nowadays. Therefore, it is of great necessity to provide the elderly with a "medical-nursing combination" service that organically combines medical and elderly care.
Since there is no standard definition of "medical-nursing combination" in China, it's defined differently by a wide range of scholars. Guo et al. believes that "medical-nursing combination", is to gradually form a cooperative service mode integrating medical treatment, recovery, and nursing from service providers (incl. hospitals, elderly nursing institutions, and communities) providing a medical and nursing service conforming to elderly nursing to the elderly in demand as per different needs of health at different stages of suffering from diseases [6]. Liu et al. defined the combination of medical care and nursing as satisfying the needs of health problems at different levels for the elderly at different stages in the care process through integrating medical resources and pension resources to optimize the allocation of medical and nursing resources [7]. Liu et al. considers that the elderly can achieve the purpose of obtaining medical treatment while suffering from diseases, and enjoying care while not suffering from diseases under the new elderly nursing mode combining medical and elderly care[8]. As for Huang et al., medical-nursing combination possesses the same concept as "long-nursing" overseas, which focuses on satisfying the basic living needs of the elderly, as well as physical and psychological care; moreover, medical treatment should be highlighted, while the enhancement of daily living skills, the adaptation of social environment, and the realization of self-worth are also important [9].
In order to solve the medical problem of the aging population, the concept of medical-nursing combination was first proposed in "Several Opinions on Accelerating the Development of the Elderly nursing Service Industry" issued by the State Council in Sep. 2013. It pointed out to satisfy the needs of multi-level elderly nursing services, actively respond to the aging population, and accelerate the development of the elderly nursing service industry through actively driving the combination of medical and elderly care service. "Guiding Opinions on Promoting the Combination of Medical Treatment and Elderly nursing Services" issued by the State Council in Nov. 2015 indicated two tasks for promoting the combination of medical and elderly care , firstly, encouraging elderly nursing institutions to conduct various forms of agreement and cooperation with surrounding medical and health institutions and establish a sound cooperation mechanism; secondly, promoting the extension of medical and health services to communities and families. In the "Thirteenth Five-Year Plan" for the Planning of Developing the Aging Industry and Constructing the Endowment System issued by the State Council in Mar. 2017, it focused on assigning 9 tasks including active promotion of medical-nursing combination service, and improving the allocation and utilization of social resources. As of 2017, China has set up 90 national-level pilot cities for combining medical and elderly care [11].
On that basis, "medical and elderly care combination" is a new elderly nursing mode that provides the elderly with services such as uninterrupted daily care, mental consolation, disease diagnosis and treatment, health guidance, recovery from serious illnesses, and hospice care through effectively integrating medical and elderly care resources, so as to satisfy varied health care needs of the elderly at varied levels.
Currently, four medical and elderly care modes can be found in China [12]. The first mode is "nursing in hospital", that is, a geriatric department is set in some large hospital with conditions to provide medical treatment, nursing, care for the elderly, rehabilitation, health education, hospice care and the like services; or some low-level primary hospitals with idle resources are transformed into nursing institutions for medical rehabilitation, convalescence, and elderly nursing to achieve the goal of integrating medical and elderly care. The second mode is "constructing hospital in nursing institutions“, and providing professional medical and nursing teams according to the standards of national hospitals in large-scale elderly nursing institutions or welfare homes. Meanwhile, basic medical departments such as comprehensive medical-surgical department, rehabilitation department, and pharmacy are set up to form a new elderly nursing institution integrating elderly nursing with healthcare functions. The third mode is the union of medical and elderly care, namely, a cooperation mechanism is established between medical institutions and elderly nursing institutions. In this way, medical institutions provide medical care training to nursing staff in elderly nursing institutions, and regularly conduct basic diagnosis and treatment services such as inspection of common diseases, chronic diseases, and geriatric diseases as well as health education. Meanwhile, the hospital also offers a green channel to provide timely medical referral service for the elderly in need, and conduct consequent recovery treatment in the elder care institutions after his/ her condition is controlled. By doing so, a two-way continuous care model is generated. The fourth mode is "home nursing", which is a family doctor model in essence. A service team provides out-patient services and life nursing services for the elderly. It is a model that is primarily designed for the elderly with good health, allowing the elderly to enjoy their old ages in peace with familiar surroundings.
As western developed countries entering the aging society is earlier than China, they have developed a new elderly nursing mode called "long-term nursing" that is consistent with the medical-nursing mode in concept, connotation, service purpose, content, and object. The United Kingdom, the United States and Japan are most typical countries that have developed their unique representative research results concerning elderly nursing.
The elderly nursing model in the United Kingdom is dominated by community and home care. Main service providers are composed of managers, professional staff and caregivers, who provide four major services including life care, material support, psychological support and overall care. Specifically, life care is mainly to provide home-care services and short-term care services for the self-care or semi-self-care elderly; material support includes the government upgrading the infrastructure of the elderly’s living place and providing tax subsidies or preferences to taxpayers more than 65 years old; psychological support is that service staff visit the elderly for health inspection, publicizing health care knowledge, making rehabilitation and treatment suggestions and providing psychological counseling; overall care is that community activity centers funded by the government or the society are constructed to inject fun into the elderly in their later years, and some low-intensity jobs are provided to increase the elderly’s income and maintain their mental health [13].
The elderly nursing model combining medical and elderly care in the U.S. is dominated by a program of all inclusive care for the elderly (PACE) that is set up for the disabled, the semi-disabled, and over-55-year-old low-income groups requiring long-term medical care. Covering medical services, rehabilitation services, social support services, the purpose of PACE is to facilitate the elderly, and the debilitated to live as long as possible in the community or family, improving the living quality of the elderly with weak self-care ability, and maximally protecting the dignity of the elderly [14]. The elderly nursing combining medical and elderly care model in Japan is dominated by the following models. First, day care center; this model mainly provides rehabilitation and life care services for the elderly more than 65 years old who are unattended at home in the daytime and need rehabilitation training. Second, nursing center; It's supported by a service consisting of nurses, caregivers, and welfare workers to provide daily services for the disabled elderly living in the center. Third, elderly welfare center targeted at the elderly in the community, service staff, mainly health care therapists provide services health examination, health education, health care services and family guidance. Fourth is the apartment for the elderly, which is mainly designed for the healthy elderly who can take care of themselves. It provides basic medical services and daily care services. An all-round legal system is a major reason why the elderly nursing combining medical and elderly care has been well developed in Japan [15].
Researches on "combination of medical and elderly care" have been proven abroad with proven systems forming from policies to services, which can provide a reference and basis for researching and implementing the combination of medical and elderly care in China. Researching the "combination of medical and elderly care" service model is still in its initial stage of development in China. Related researches in the domestic literature focus on introducing and analyzing foreign elder care cases based on the "combination of medical and elderly care ", which propose the status quo of the development of the "combination of medical and elderly care" mode before making suggestions, or conducting case study in the pilot region of combining medical and elderly care in China. Nevertheless, few studies cover the service requirement and influencing. Instead, most of the researches discuss the elderly’s basic situation, health status, social support, and income status, etc. Generally speaking, the better the health condition of the elderly, the higher the self-care level, the lower the income, and the lower the social support, the smaller the demand of the service combining medical and elderly care [12, 16]. Li et al. finds out that the number of children, health status, children support, and willingness to pay have significant impacts on the demand of services combining medical and elderly care after investigating more than 420 elderly people aged more than 60 years in four major urban areas of Chongqing [16]. Hu et al. discovers that degree of education, ideal elderly nursing way and willingness to pay are significant factors affecting the elderly’s demand of the service combining medical and elderly care in urban areas after surveying the elderly in Yinchuang [17]. According to Zhao et al's research, age, degree of education, number of children and occupation type before retirement are main factors affecting the elderly’s demand of the service combing medical and elderly care[18]. Through investigation, Wang et al's believes that the elderly in Changchun has a high willingness to participate in the combination of medical and elderly care. Gender, age, education, and occupation type are major factors affecting their choices [19].
The basis of medical insurance in China is comprised of basic medical insurance system for urban workers, basic medical insurance system for urban residents and new rural cooperative medical insurance [20, 21]. A unified basic medical insurance system for urban and rural residents should be gradually established nationwide according to the Opinions on Integrating the Basic Medical Insurance System for Urban and Rural Residents issued by the State Council in 2016. The number of people insured in basic medical insurance in China has exceeded 1.35 billion with a participation rate maintaining at over 95% by the end of 2017, basically realizing a full coverage from "insurance for few" to "insurance for all" [22].
The basic medical insurance system for urban employees is raised jointly by social medical unified planning and individual account, forming social medical unified planning fund and individual medical account fund. Individual account is not set in the basic medical insurance system for urban and rural residents. In other words, only social medical unified planning fund is established to raise funds through quota. The premiums consist of individual residents' contributions and financial subsidies.
Most scholars in our country believe that the demand of the service of combining medical and elderly care is affected by the design and implementation of medical insurance systems and the elderly’s paying capacity under the current medical insurance system. In terms of system design, there is a lack of long-term care insurance specifically for elderly nursing, and the elderly nursing service combining medical and elderly care is not involved in the designated medical insurance units. Medical insurances in China focus on economic compensation for the loss caused by the disease, lacking compensations for preventive health care, rehabilitation, long-term care, and the like services needed by the elderly, whereas basic pensions are mainly used for daily care of the elderly [23]. In the aspect of system implementation, the reimbursement practice of medical insurance in China is characterized by" designated medical care with three medical directories". Since setting up medical institutions in nursing institutions is not included in the designated medical organization, additional medical services in the nursing institution cannot be paid through medical insurance. In the case, the elderly living in the nursing institution have to visit hospitals for treatment, lowering the access of medical service [24]. Besides, a plurality of issues such as the admission of nursing institutions, the verification of medical qualifications, medical insurance designated hospitals, and review and distribution of charges can be found in the nursing institution involving in the combination of medical and elderly care [25]. Regarding the elderly’s paying capacity, the medical insurance only covers medical expenses and examination costs during the medical process. And with the lack of the long-term care insurance system, rehabilitation medical programs, life care programs, and auxiliary equipment programs are fully paid by the elderly. However, the elderly patients who are economically disadvantaged, especially the disabled and the semi-disabled, the elderly suffering from diseases, and more than 80 years old have a limited capacity to pay for the long-term care cost [26].
The elderly is a main service object of the "medical-nursing combination" model, whose demand willingness plays a decisive role in the development of the "combination of medical and elderly care ". Hence, it is absolutely essential to proceed from the elderly’s demand and willingness before conducting an in-depth exploration of the elderly nursing mode combining medical and elderly care.
As of the end of 2018, the elderly aged 65 years old or above in Lanzhou has reached up to 498,800 people, accounting for 16.50% of the total population [27]. Moreover, the proportion of the population aged 65 years old or above has been apparently higher than the average level of the whole country and Gansu during the same period (See Fig. 1. Data source, national data from 2010 to 2018 were from the China Statistical Yearbook [27], and data of Gansu from 2010 to 2018 were from the Gansu Statistical Yearbook [28], data of Lanzhou from 2010 to 2018 were obtained from the Lanzhou Yearbook [29]). In addition, as can be seen from Fig. 1, the degree of the aged phenomenon has becoming more serious in Lanzhou from 2010 to 2018, of which, the aging rate was 8.20% in 2010 and jumped to 16.50% in 2018, indicating that the growth of aging population has been accelerated by 8.3%. By comparison, the national aging rate was 11.9% in 2018, which clearly shows that the aging rate in Lanzhou was accelerated. What's worse, the aging problem in Lanzhou would be crucial, as the degree of aging population could become serious over times. The accelerating population aging speed in Lanzhou has brought tremendous pressure on elderly nursing. Furthermore, elderly nursing involves a variety of requirements such as medical rehabilitation and spiritual happiness with the social progress, rather than merely basic daily care. It can be seen that a tremendous requirement has been proposed to multi-integrated nursing services combining nursing and medical treatment based on the huge elderly group and the serious aging status quo in Lanzhou.
Incomplete statistics show that there are 27 nursing institutions in Lanzhou as of now, including 7 institutions run publicly and 16 run privately, and 4 institutions combining medical and elderly care, proving a total of 6,107 beds. Specifically, 18 hospitals have set up geriatrics and geriatric beds, providing a total of 500 beds, accounting for 69% of the total number of hospitals; 26 hospitals above the county level have set up green medical treatment channels for the elderly; and 19 nursing institutions can provide medical services, accounting for 70.4% of the total nursing institutions; the contracted service rate of the home-based elderly aged more than 65 years old in Lanzhou reached up to 73% [30-31]. As a national pilot city for combination of medical and elderly care, Lanzhou has made some achievements in the process of developing service combining medical and elderly care. However, the follow-up work remains cumbersome since the policy obstacles of combination of medical and elderly care should be overcome. What's more, concrete service contents and links should be improved, such as constrained nursing conditions in medical institutions, missing service function of nursing institutions, high cost, constrained reimbursement of medical expenses, pessimistic cognitive status of the concept of combination of medical and elderly care , and the institution management system requiring enhancement [31].
Scholars tend to be more willing to concentrate on the process and obstacles of combining medical and elderly care at the macro level for such a new type of elderly nursing. However, few studies analyzing the elderly’s needs of combination of medical and elderly care can be found.
The social and economic foundation of the undeveloped region of western China is relatively weak with a low level of social security and welfare. In particular, the elderly long-term care system in remote rural areas is in its infancy. Lack of a well-defined medical nursing mechanism seriously affects well-being and happiness of residents in the area. As the driving strategy of combining medical and elderly care has been vigorously promoted at the national level, theoretical introduction and countermeasure are essential to regional strategic layout. A questionnaire survey concerning the needs of elderly nursing service combining medical and elderly care was conducted on residents in Lanzhou. On this basis, specific needs of residents for elderly nursing services combining medical and elderly care were analyzed. By sorting out factors affecting the demand of elderly nursing service combining medical and elderly care, policy proposals were proposed accordingly. And the case study of Lanzhou was taken as an example to provide a referring significance of developing combination of medical and elderly care in the undeveloped region of western China, so as to lift health care levels of residents in the undeveloped region of western China, satisfy their medical and nursing requirements, and improve their nursing services.