Table 2 Design features of Joint Health Center (JHC) for chronic care in Hangzhou City

Target population

NCDs patients, with a particular focus on diabetes and hypertension patients at the initial stage.

Provider network

Four tertiary hospitals and forty-six CHCs participated the providers network. The networks were constructed according to the geographic location, and each tertiary hospital was designated to collaborate with the CHCs in the same or nearby district.

Organizational structure

Each CHC was responsible for the establishment of a local JHC based on its existing medical resources, especially for the preparation of a well-equipped consultation room for integrated care. Forty-six JHCs with a unified logo were founded in the CHCs.

Healthcare personnel

The CHC’s director was assigned to be the JHC’ director, in charge of its operation. Directors of hospital were in charge of the coordination with CHCs and selection of specialists. The JHC had a team of medical staffs consisting of the chief general practitioners (GPs) and nurses from CHCs, and specialists from hospitals. Chief GPs from CHCs played the gatekeeper role and guided NCDs management, and specialists from hospitals collaborated with chief GPs to provide integrated care and to train chief GPs. An innovative mentorship system was first introduced between chief GPs and specialists.

Integration mechanism

The CHCs and hospitals signed the cooperation agreement for NCDs management. The primary care and specialist care were integrated and delivered to the NCDs patients through the JHCs.

Scope of services

The scope of services included the integrated care of primary health care and specialist care in the JHCs, and the care in coordinated hospitals. The patients were reasonably referred to different levels of care facilities based on their medical conditions and were followed up by their chief GPs.