A Study on the Development of a Model for Providing Traditional Korean Medicine and Welfare Services for Community Care.

Objectives: This study aims to develop a community care model in traditional Korean medicine (TKM) by developing a community care participation model for the health of the elderly and deriving tasks to implement it.
Methods: This study implemented a group interview with experts. A fact-finding survey was conducted targeting 16 local governments that are implementing a leading project to identify the status of TKM service provision and welfare service linkage in all regions. An expert group interview (FGI) targeted public and private sector experts for each job role, the former represented by those in charge of the central government's health care policy and administrative delivery system, and the latter by professors majoring in social welfare, professors majoring in health, and local TKM societies. After forming the expert groups, three expert group interviews were conducted.
Results: Through collective interviews with experts, a model for providing TKM and welfare services in community integrated care was derived by dividing it into local and central government levels. The strategies and tasks for promoting TKM-oriented health welfare services were derived from 3 strategies, 8 tasks, and 20 detailed tasks.
Conclusion: The core direction of the TKM health care model is the region-centered provision of TKM and welfare services. To this end, policy support for the use and linkage of health care service resources is required at the central government level, and linkage and provision of health welfare services centered on TKM are necessary through linkage and convergence between service subjects and between government health care projects.

INTRODUCTION

With the advancement of modern medical technology and the extension of the human life span, there is an increase in aging globally [1]. South Korea has become an aging society, with 14% of the total population since 2017 being older adults. In addition, it is expected that by 2025, the country will enter the phase of an ultra-aged society, where the elderly population accounts for 20% of the total population [2]. Such increases in the number of elderly people will entail increased burdens for the state in terms of health care, which will result in more socio-economic encumbrance. Therefore, the state must be more responsible and control this issue [3-6].

The low birth rate and aging of society have diversified the forms of families and promoted a culture of individualism, where independent individuals have prevailed over the communities that are based on Confucian traditions. According to statistics regarding older adults in 2015, about 90% of individuals in the 1990s thought they were responsible for supporting their parents when they got old. However, the number of people who believe this began to shrink in the early 2000s, falling to less than 40% in 2012. This downward trend is expected to continue in the future [7]. While the sense of responsibility for supporting the elderly population has weakened, the level of preparedness among the elderly to support themselves in old age remains low. Therefore, the state must further be responsible for and manage the support of the elderly population [3]. Moreover, since the introduction of the long-term care insurance program in 2008, the number of long-term care and nursing facilities, including nursing hospitals, has increased rapidly. However, these facilities are available only to the elderly who are eligible for long-term care insurance coverage [8, 9].

To solve the issue of providing care and supporting elderly populations without coverage, the South Korean government established the “Basic Plan for the Integrated Community Care Program,” intending to establish an integrated system of community care in the country [10]. The four major objectives of integrated care, which aim to establish an elderly care system in local communities, are to provide customized residence support, promote home-visit care and health management, expand nursing and care services, and join and integrate people-centered services [10]. Pilot programs for integrated community care programs were also conducted in 16 regions and municipalities to build integrated care systems in 250 regions and municipalities by the year 2025 [11].

Globally, other countries have also introduced community care as a solution to the aging society. Japan amended its Nursing Act in 2005 to establish integrated community centers to provide everyday health care services by linking different sectors centered around beneficiaries [12-14]. The United Kingdom revised its national health laws and community care laws in 1990 to put local governments in the center position and provide various services based on users’ desires [15-17]. In Sweden, the Social Service Act was enacted in 1982 to proceed with its elderly care services, where local governments play a central role. Based on the desires of the elderly, a team of family doctors, nurses, and social workers is formed to evaluate the desires of the elderly and establish a care plan. This care plan then becomes the basis for providing the beneficiaries with various integrated services, including home-visit care, recuperation, rehabilitation, and everyday support [18].

In a previous study, Sung et al. [19] investigated traditional Korean medicine (TKM) services in the public sector and suggested that government policy development is necessary for integrating TKM into the community care system. The current study aims to develop policy models and strategies to facilitate the traditional medicine sector’s participation in community care. In particular, the researchers intend to set the direction for policies regarding how to link, combine, and provide traditional medical services and welfare services in the public sector.

1. The current status of the provision of TKM services

The researcher conducted a survey to understand the current status of the provision of TKM services and their connections with welfare services in the pilot project areas for the integrated community care program of the Ministry of Health and Welfare. The survey was conducted by the National Institute of Korean Medicine Development by sending an official letter to 16 localities that participated in the pilot program from September 1 to September 15, 2020, to investigate the current status of the TKM health care services in 2020. The survey covered project durations, targets, applicable diseases, services provided, and linked services and consisted of open-ended questions. The participants who were eligible for the TKM services were instructed to name any public services they received to learn about the linked services. The researchers gathered and summarized the questionnaires returned. Any items with missing information were complemented by requesting the responsible local government officers who participated in the survey to provide more information. The project period, targets, diseases, and services provided by the localities were summarized using survey items. The current status of linked services was integrated as per the most important categories in the standard classification system for welfare resources (draft) (Fig. 1).

Figure 1

Current status of health care-linked services for traditional Korean medicine.

The current status of the TKM services was provided by 13 of the 16 localities (81.3%) that participated in the integrated community care pilot program created by the Ministry of Health. All these programs involve health-care providers visiting the locations of the beneficiaries. Eleven localities provided home-visit care, while one provided a program wherein providers visited community facilities. Nonetheless, another locality provided both home-visit and facility-visit programs. Twelve localities provided traditional medicine programs for the elderly, while one provided services for the handicapped.

MATERIALS AND METHODS

This study conducted focus group interviews (FGIs) to develop models for the promotion and facilitation of TKM-based care services and implementation strategies. An FGI is a qualitative study method designed to obtain opinions and feedback from participants regarding certain topics. The advantage of this method is that the researcher can directly consider the views and experiences of individuals regarding the topic or issues [20]. In addition, for focus groups equipped with experience and knowledge regarding certain topics, detailed information on selected topics may be obtained [21].

1. The composition of the focus group

The participants in this study comprised 5 experts each from the public and private sectors, with 10 experts in total. The public sector experts were, respectively, a public official from the central government responsible for health-care policies, an officer responsible for the administrative delivery system, an officer from the local government who was responsible for the provision of integrated community care services, and an officer from a public authority responsible for conducting health promotion programs through community health centers. The five private-sector experts consisted of the following: a professor who majored in social welfare, another professor who majored in public health, the local TKM practitioners’ association, an honorary traditional medicine professor, and civic groups (Table 1).

Table 1

Composition of the expert group

Public sector				Private sector
ID	Sex	Expertise field		ID	Sex	Expertise field
1	F	Health medical policy		1	M	Social welfare policy
2	F	Administrative service delivery system		2	M	Health policy
3	F	Community care service		3	M	TKM service of community
4	M	Community care service		4	M	TKM policy
5	F	Health promotion service of public health center		5	F	Representative of civil group

F, female; M: male; TKM, traditional Korean medicine.

The composed participants were organized to determine, advise, and consult on major issues with the aim of strengthening primary medical care and providing health care through the linkage of health welfare resources in the community. A total of 15 experts were selected as research participants through the following process.

First, department managers for the establishment of a comprehensive plan for the development of oriental medicine at the central government level, community care managers for providing administrative and financial support through links with related projects, and other central government-like projects were selected.

Second, in order to prevent diseases, manage health care, and provide social welfare convergence content services through oriental medicine, integrated health promotion project managers, oriental medicine service providers, experts for providing welfare services, and representative civic groups were selected.

2. Focus group interview questionnaire

A total of three meetings were held with experts in related fields to establish a plan to promote the TKM health care service in community care. Before conducting the FGI for the promotion plan of the TKM health care service, the researchers set up a questionnaire consisting of six questions (Table 2).

Table 2

Interview questionnaire for TKM promotion strategies

Major tasks	Question for group meeting
Strengthening the linkage of TKM health care	1) What do you think is a way to provide TKM and strengthen the connection of welfare services?2) What do you think is a way to revitalize health promotion using TKM in the existing health care delivery system and health centers?3) What do you think is a way to establish a support system to revitalize and maintain TKM health care?
Standardization of TKM health care and establishment of an institutional foundation	1) What do you think is a way to provide standardized and realistic TKM health care services?2) To strengthen the capabilities of TKM health care professionals, who should be provided with what programs?3) What do you think are the necessary measures and evaluation methods for linking TKM health care and welfare services?

TKM, traditional Korean medicine.

3. Development process model for the provision of TKM health care service

First, the researchers formed focus groups with experts from different service categories (e.g., social welfare and TKM) and held three focus group interviews. During the first interview, information on the current status of the TKM services and the implementation of the program provided in the pilot program areas for integrated local community care was shared, and the initial design of the TKM service model was developed. The TKM health care service refers to a health and welfare service that combines what existing health and welfare services provide using TKM. The TKM service model includes TKM doctors, nurses, social workers, and nursing care workers who play a role in the existing health care and welfare delivery system and provide services using TKM in the existing regional care service system.

During the second interview, the standard model developed during the first interview was further specified, and implementation strategies for realizing it were identified. The system for actual practical performance was specified for the inter-job linkage developed in the first interview, and the standard model was linked to the existing local care system and health care system. It was judged that a system such as a support group or promotion committee to provide TKM services and care services such as the central government, public institutions, local communities, and related experts and to support the establishment of TKM services is needed in detail. Accordingly, a promotion strategy was established to strengthen the linkage of TKM services, promote TKM services within the health care system, and organize and operate a cooperative system to revitalize TKM services. It also developed and distributed standardized manuals (to standardize TKM services and to establish an institutional foundation), provided technical support for TKM services in the local community, and established a promotion strategy to monitor and evaluate services.

Finally, during the third interview, the implementation strategies identified during the second interview were used as the basis for identifying objectives and tasks. The goals and tasks to be implemented in the second interview were discussed. The goal was to form a project support group that could utilize the existing local care system and share the support system through consulting and workshops on TKM services. In addition, promoting linkage between projects in public health centers through consulting on health promotion programs by life cycle at public health centers was a detailed task, as was preparing measures to revitalize health care for TKM by selecting excellent cases and evaluating performance. In order to standardize TKM health care and establish an institutional foundation, a detailed task was to develop a standard manual for providing TKM services for each life cycle and to investigate linked cases focused on health and welfare services.

RESULTS

1. Developing a model for the provision of TKM health care service

Through expert consensus, the researchers developed a model for the provision of TKM health care services as part of integrated community care (Fig. 2). At the local community level, two types of links were suggested. The first is to combine and link the services provided by different service providers. This necessitates securing a system of communication between localities and preparing a manual for the provision of linked/converged services. The second option is to link and converge the health welfare services provided by different localities (including integrated community care, health-governance public service programs, and health management programs by community health centers) and TKM services. It is expected that various link-up/convergence models can be used to monitor services in different localities. As for the targets of the services, it was planned that health welfare services based on TKM aimed at different stages of the life cycle would be established within local communities. The central government operates a support group and an implementation committee, which allow local communities to provide TKM health welfare services.

Figure 2

A model for providing TKM and welfare services for community care promotion. TKM, traditional Korean medicine.

2. Developing the implementation strategies and objectives for the TKM-based health-care services

To implement the TKM health welfare service provision model, the following implementation strategies and objectives for a health welfare service centered on TKM were identified (Table 3). There were 2 implementation strategies, 6 objectives, and 16 tasks. First, for the implementation strategy “strengthening the links with TKM health care,” local communities are to provide TKM services as part of public services and link/converge them with health welfare services as the key direction of implementation. Based on this, the objectives were selected. Furthermore, the researcher selected the objectives intended to invigorate the linkage with the local health promotion programs and establish a TKM health management support system. In the second implementation strategy, “standardizing TKM health welfare and providing an institutional basis,” the objectives were focused on providing standardized TKM services that satisfy the minimum quality requirements. Other objectives, including developing and providing a standard manual for TKM health care, training service provision specialists, and monitoring and evaluating the provision of TKM health care services, were selected.

Table 3

Strategies for health and welfare services based on TKM

Major tasks	Main tasks and sub-tasks
1. Strengthening the linkage of TKM health care	1) Providing TKM and welfare services linkage reinforcement(1) Providing health care for TKM within community care for local communities and strengthening connections(2) Providing health care and strengthening connections to TKM health care within the public service (government) level(3) Discovering and disseminating cases of health care connection regarding TKM
	2) Activation of the health promotion of TKM at public health centers(1) Staff in charge of TKM health promotion businesses (e.g., TKM doctor, nurses), strengthening the linkage between other projects in the health center(2) Selecting and rewarding excellent organizations and projects for performing TKM health promotion projects
	3) Establishment of a TKM health care support system(1) Composition and operation of the TKM health care promotion committee(2) Organization and operation of support groups for TKM health care(3) Organization and operation of regional working-level councils
2. Standardization of TKM health care and establishment of an institutional foundation	1) Development and dissemination of a standard manual for health care in TKM(1) Review and advancement of the existing TKM service provision manual(2) Development of guidelines for health care linkage of TKM and welfare services(3) Preparation of clinical basis for the provision of TKM services
	2) Professional manpower training education(1) Operation of training programs for professional personnel to provide TKM services for TKM doctors(2) Development and operation of training programs for professionals in TKM and welfare services, such as nurses and social workers(3) Conduct training and meetings for personnel in charge of local government projects
	3) TKM and welfare service monitoring and evaluation(1) Monitoring of TKM and welfare service by region(2) Securing business continuity through evaluation (effectiveness, economic feasibility) of TKM and welfare services

TKM, traditional Korean medicine.

DISCUSSION

The increase in the elderly population is gaining more attention since their health issues affect all of society. Previous studies on elderly populations emphasized that many elderly individuals have chronic health issues due to their age; therefore, regular health management and preventive efforts are important [22, 23]. For this, the researchers developed a TKM-centered health care service standard model in communities and their implementation strategies based on the advantages of TKM in responding to the need for a solution for care in the face of rapid aging. This was done to expand the role of TKM in community care systems.

This study was intended to help develop a community care model in the field of TKM by identifying the implementation objectives of an integrated community care model focused on TKM. For this purpose, first, the researchers investigated the current status of TKM service provision and its linkage with welfare services in 16 regions/municipalities participating in the integrated community care pilot program. As for the linking-up with the health and welfare services provided to the beneficiaries, everyday life support, physical health and health care support, residential welfare, and mental health/emotional support services accounted for 48.7%, 31.7%, 10.6%, and 9%, respectively. Based on the results of the evaluation of the current status of linkage, a focus group was formed to develop a service provision model for TKM health care services, along with the implementation strategies and objectives. At the local community level, two types of links were suggested. First, services are required to link up and converge between service providers, while a communication system between service categories and a manual for service providers must be developed. Second, linkage and convergence of different types of services through the monitoring of services in different localities are needed in the form of connecting health welfare and TKM services provided by localities.

The implications of this study are as follows. First, with a standard health care service model centered on TKM, a foundation to link local health care systems with TKM was laid, making it possible to form a health care system centered on TKM. The disease must be managed continuously to link the health and welfare of beneficiaries within a community care system. Given that TKM can provide preventive health management and health education in addition to the diagnosis and treatment of diseases, TKM has a positive impact on the promotion of health within community care systems [24, 25].

Second, it is now possible to organize the previous fragmented projects executed by the TKM associations and local authorities and run them more efficiently within the TKM health care system. Given that the services are currently provided in a fragmented manner in different service categories, there were limitations in linking community care services, focusing on beneficiaries [26]. However, given that it is easier for TKM practitioners to make home visits, it was possible to provide physical, psychological, and emotional services to the beneficiaries in need of social care [27]. Furthermore, a foundation was laid to explore possible options to link TKM services and provide integrated services by forming a system of cooperation between different service categories within the existing systems of care in local communities [28, 29].

The limitations of this study are as follows. First, most of the TKM services provided home-visit services to the elderly. However, these services are being provided in different ways among local communities. Therefore, a certain level of standardization must be achieved by developing and proliferating a centralized, standard TKM service manual [30, 31]. In particular, the standard manual should include the minimum staffing requirements and roles of staff members in providing the services so that local governments may run these programs effectively. In addition, training and consultations should be provided in the field to enhance acceptability.

Second, this study examined the current status of linkage in TKM health care. Furthermore, studies for developing customized health care linkage models will be necessary in order to develop care services that can recommend linked services to the TKM services recipients. Forums and discussion bodies are also needed to increase the level of understanding of TKM health care and continuity in linkage. The platforms are to be run with the TKM service beneficiaries at the center to provide services that can serve the desires of the beneficiaries and build a system of communication between different service categories. Finally, TKM care programs have been expanded from 9 localities in 2019 to 13 in 2020. However, there are limitations to the amount of support provided by the central government. For this, it may be necessary to proceed with standardization, monitoring, and effectiveness evaluation of TKM health care programs, so that a foundation can be laid for the central government to provide support to invigorate TKM health care services.

CONCLUSION

The key implementation strategy for TKM health care is for the community to serve as the focal point of TKM services and health welfare services. However, it is difficult to expect the TKM health care model to be realized considering the demand among local residents and the efforts/capabilities of local governments. Therefore, the central government should support local authorities so that they can take a leading role in utilizing and linking resources efficiently. In particular, key strategies for realizing the TKM health care model would include the central government providing minimum guidelines and identifying cases of TKM health care services in localities to reward them accordingly.

One strategy of the government to implement the community care program is linking and integrating services, focusing on beneficiaries instead of facilities. Therefore, to link fragmented services, a cross-disciplinary team must provide beneficiaries with integrated care services. This is a model of the linkage and convergence between service providers. A model wherein the integrated care program of the government and the health management program of community health centers, which includes TKM services, are linked with health and welfare services must be considered favorably. These two approaches will lay the foundation for linking and providing health welfare services focusing on TKM and will replace existing, fragmented services.

AVAILABILITY OF DATA AND MATERIALS

The datasets used and/or analyzed during the current study are available from the corresponding author upon reasonable request.