Based on the analysis framework mentioned above, this article focuses on the dimensions of demand embedding, resource embedding,主体 embedding, and concept embedding in community embedded elderly care, systematically sorting out the service projects, service facilities, and operational models in community embedded elderly care, in order to better present the overall picture of the current development of community embedded elderly care in China.
Based on the relevant policy documents released by some leading regions and recent research findings, this article roughly categorizes the service projects of community embedded elderly care into professional care, meal services, medical care, emotional comfort, spiritual culture, technical support, and other services. Each category includes different service projects, as detailed in Table 3.
First, the professional care sector is the core of community embedded elderly care. This type of service focuses on addressing the questions of “where to care,” “who will care,” and “how to care” in traditional elderly care models. Since the service projects in this sector (especially day care and short-term care) have strong integration and nesting attributes, some scholars have equated this type of service directly with community embedded elderly care. However, with the enrichment of the relevant service connotations and the diversification of embedding forms, the relationship between the two can be further clarified.
Second, meal services and medical care are the basic components of community embedded elderly care. These services primarily meet the two major needs of elderly people in the community: dining and medical care, corresponding to the most basic physiological and safety needs in Maslow’s hierarchy of needs. Therefore, the total demand for related services is relatively large, and the urgency is higher. Nowadays, meal services and medical care have become key supporting sectors in the construction of community embedded elderly care services.
Third, emotional comfort, spiritual culture, technical support, and other services are important supplements to community embedded elderly care. These services can better meet the multi-layered and personalized material and spiritual needs of elderly people in the community, improving their quality of life, corresponding to the advanced social, esteem, and self-actualization needs in Maslow’s hierarchy of needs. However, due to differences in community infrastructure and development levels among different regions, the promotion of service projects in these sectors is generally lower, and the development gap among different regions is relatively larger.
Home, community, and institutional facilities are important spatial carriers for the sinking of socialized elderly care service resources to the grassroots. Based on the placement locations, functional positioning, and service cycles of different service facilities, this article specifically divides community embedded elderly care service facilities into three categories: home-based, community day, and institutional residency, with details of each category and the main service facilities corresponding to each type shown in Figure 2.
First, home-based facilities. These primarily target elderly groups who are long-term home care recipients, with representative facilities being various types of home aging-friendly designs, such as safety handrails, non-slip floors, indoor sensor lights, elderly-friendly furniture, smart home devices, and monitoring call systems. These aging-friendly home facilities can effectively reduce the difficulty of elderly people’s home activities, and some smart devices even have networking functions such as risk warnings and emergency assistance. The multi-form, multi-scenario, and multi-functional home facilities work together to create a safe, convenient, and comfortable home care environment for the elderly.
Second, community day facilities. These include two types: day activity-oriented and day care-oriented. The former primarily targets elderly groups with intact mobility and relatively good health. From the perspective of functional integration, this type of facility can be further divided into single-type (e.g., community senior dining halls) and composite-type (e.g., comprehensive elderly service centers, community life stations). Relevant facilities widely cover a series of functions such as dining, socializing, culture and entertainment, sports, and education, which can better meet the multi-layered elderly care needs of elderly people in the community, improving their quality of life. The representative facility for the latter is community day care centers that provide day care services.
Third, institutional residency facilities. These include short-term and long-term residency types. The representative facility for the former is community elderly care homes, which provide full-time care services for elderly people and families in need (e.g., when there is no one to care for them at home temporarily or when they need short-term rehabilitation due to illness). To allow more elderly people in the community to receive care, short-term residency facilities usually impose restrictions on the residency period of elderly people. The representative facility for the latter includes community elderly service centers and other institutions. Additionally, some scholars have also categorized the gradually emerging elderly communities in recent years under this type of facility.
Current domestic scholars mainly classify the operational models of community embedded elderly care from two perspectives: one is based on the overall characteristics of geographic regions, such as Shanghai model, Beijing model, Chongqing model, Hefei model, Shijiazhuang model, etc.; the other is based on specific service performance forms, such as “Party Building + Elderly Care” model, “Property Management + Elderly Care” model, and elderly care station model.
Similar to traditional institutional elderly care, the development of community embedded elderly care relies on the government, but also requires broad social participation. Different entities perform their respective roles and embed with each other, resulting in a rich variety of operational models. Based on this, this article summarizes five main operational models of community embedded elderly care based on the nature of the investment and operational entities involved in the elderly care service supply process, as detailed in Table 4.
Overall, the current five operational models of community embedded elderly care have distinct characteristics, each with its own advantages and disadvantages. Among them, the public-private partnership model has the highest popularity nationwide and holds an absolute position in economically developed provinces and cities such as Beijing and Shanghai. This is currently the most typical operational model in community embedded elderly care. Under the public-private partnership model, the cooperation forms between the government, market, social organizations, and individuals are more diverse, and the threshold for service operation entities is relatively loose, which gives this operational model good practical operability and regional applicability.
In addition, the public-private partnership model can maximize the activation of social elderly care service resources, promoting high-quality services to sink to the grassroots, thereby better realizing the basic functional positioning of community embedded elderly care—allowing more elderly people to conveniently access high-quality and inclusive elderly care services.
In contrast, the private-public assistance model is more prevalent in areas with limited local fiscal capacity. Under this model, the construction funds for community embedded elderly care service facilities are mainly raised by private entities, and local governments only need to provide some site and financial support, thus helping to further reduce the fiscal expenditure pressure on localities. The market operation, collective economy, and charitable mutual assistance models are more niche, where the market operation model mainly targets elderly groups with a certain economic foundation and a focus on quality of life, the collective economy model is mainly found in regions with relatively developed village collective economies, and the charitable mutual assistance model is mainly found in rural and other underdeveloped areas.
Despite the fact that some provinces and cities have achieved certain results in community embedded elderly care, it is still in the exploratory stage of experience. Community embedded elderly care in China still faces multiple challenges from demand embedding, resource embedding,主体 embedding, and concept embedding in practice, which deserves deeper reflection.
On one hand, the supply-demand relationship of community embedded elderly care services presents an overall imbalance. Influenced by traditional filial piety concepts, many elderly people are still unwilling to enter any social elderly care venues or facilities, nor are they willing to accept socialized elderly care services provided by non-family members. In addition, some elderly people are relatively unaware of community embedded elderly care, and they hold a more rejecting or cautiously observing attitude towards such elderly care facilities and services, which also suppresses their related elderly care needs.
On the other hand, the supply-demand relationship of community embedded elderly care services presents a structural imbalance, specifically manifested in two aspects: one is the mismatch of service project supply and demand. Surveys have found that many communities arrange different learning courses and cultural activities for the elderly every day, but the actual effect of these schedules is often unsatisfactory, frequently resulting in polarized issues of sometimes being “overcrowded” and sometimes “unattended.”
Clearly, this is caused by the service providers’ inability to accurately grasp the needs of the elderly and their difficulty in flexibly adjusting service supply strategies. This formalistic and rigid service supply model leads to a waste of elderly care service resources. The second is the mismatch of supply and demand among different regions, which is concentrated in the geographical space where the layout of community embedded elderly care service facility points is not coordinated with the scale and density of the elderly population in the region.
Overall, the dual imbalance of the supply-demand relationship reveals the absence and inadequacy of the demand linking mechanism in the current development of community embedded elderly care. Although many regions have established digital elderly care information service platforms, the research process has found that most platforms are flashy but impractical, with missing basic data, outdated information, insufficient information accuracy, and system network delays, making it difficult to “find services for people.”
Taking talent resources as an example, the current elderly care service industry in China is labor-intensive. Due to the high work pressure at grassroots positions, low salary levels, low social recognition, and limited development space, community embedded elderly care development is facing a serious personnel crisis, manifested in three aspects:
First, structural imbalance, the service team presents an aging characteristic, with practitioners aged over 50 becoming the norm, and there are few young frontline personnel joining, showing a significant lack of development vitality. Additionally, the gender ratio of the service team is severely imbalanced, with males generally less willing to engage in related work;
Second, insufficient qualifications, practitioners generally have low educational levels and lack of professional knowledge and skills. In some rural and underdeveloped areas, some practitioners can directly take up positions without professional training or relevant qualifications, which may affect the quality of elderly care services and leave service hidden dangers;
Third, high turnover rates. During the research process, it was found that due to similar job attributes, many practitioners choose to switch to the more relaxed and less stressful domestic service field after working in institutions for a period of time. Therefore, institutions need to frequently recruit employees and retrain them, and this high-frequency personnel turnover not only increases the cost of elderly care services but also affects service quality, which is not conducive to the long-term stable development of community embedded elderly care.
In addition to frontline personnel, the development of community embedded elderly care also relies on specialized management. However, there are significant differences in the industry backgrounds, resource bases, concept orientations, and professional levels of operational entities, which may lead to significant differences in the quality of community embedded elderly care services provided in various regions. The construction of relevant elderly care service evaluation systems and standardized management remains a heavy task.
The current operational models of community embedded elderly care are rich and diverse, and the participating entities in different models also show diverse characteristics in practice. Therefore, in various links involving multiple parties’ interests and responsibilities, a series of coordination issues inevitably arise:
First, the construction of community embedded elderly care service facilities may to some extent encroach on community public land resources. The renovation and subsequent operation of facilities may also have negative impacts on community residents (noise pollution, influx of outsiders, etc.), which can trigger residents’ resistance and behaviors, leading to a NIMBY effect;
Second, during the construction and operation of community embedded elderly care service facilities, private entities face strict qualification reviews, with fire safety reviews being particularly prominent. Complex review procedures, lengthy review cycles, and strict review indicators significantly increase the costs and pressures of facility operation, which is not friendly to some “grassroots” operators;
Third, for public-private partnership and private-public assistance operational models, depending on different contract types, the management rights and operational rights, ownership and usage rights of community embedded elderly care service facilities may exhibit varying degrees of separation, leading to deviations in action logic, competition between public and private entities, and operational direction biases.
In addition, these issues also reflect the constraints of funding and land in the development of community embedded elderly care. The former is concentrated in difficulties in timely and sufficient issuance of fiscal subsidies, and the limited risk resistance ability of small and micro institutions, while the latter is focused on the limited availability of land resources in communities and the difficulties in approving land for facility construction.
Community embedded elderly care in China originated in Shanghai, a city with strong economic strength and a high level of urbanization. During the long-term exploration and practice of this elderly care model, Shanghai has accumulated relatively rich experience. However, whether these experiences and paradigms are equally suitable for other regions is evidently negative.
China is vast, and there are significant differences in natural geographical characteristics, economic development levels, population composition, and local cultural concepts among different regions. Therefore, it is challenging to promote a standardized elderly care model nationwide, which is particularly evident in:
First, the differences between developed and underdeveloped regions. Developing community embedded elderly care requires investment in land, labor, technology, and other resources, all of which ultimately rely on substantial financial support. The elderly care service industry has the special attributes of high upfront investment and long return cycles, making it difficult for economically backward regions with limited fiscal revenues to develop this elderly care model.
Second, the differences between urban and rural areas. Unlike cities, the foundational aspects for developing community embedded elderly care in rural areas are relatively weak, and the social resources available for integration are extremely limited. Most rural communities need more support to develop this elderly care model. In addition, influenced by strong filial piety concepts, rural elderly people’s acceptance of social elderly care is lower than that of urban elderly people.
Third, the differences between plains and mountainous areas. Compared to plains, mountainous areas have more complex terrain, more closed transportation, and scattered resident distributions. The communities here are no longer the communities perceived under the “plain thinking” cognition. Promoting community embedded elderly care in mountainous areas will face greater cost issues and a series of fairness issues in resource allocation.
In March 2023, Premier Li Qiang pointed out during a survey in Hainan that “home-based elderly care is the primary form of elderly care in our country. We should actively explore community embedded elderly care services around the expectations and needs of elderly people, addressing their needs for meals, medical care, and more.” In May of the same year, the Central Committee of the Communist Party of China and the State Council issued the “Opinions on Promoting the Construction of the Basic Elderly Care Service System,” with the implementation of the national basic elderly care service list being listed as a key focus of national elderly care work in the near future.
As the basic unit for residents’ lives and social governance, communities are the “last mile” for implementing the sinking of elderly care service resources to the grassroots and promoting the comprehensive implementation of basic elderly care services. This article believes that the important foundation for the development of elderly care services in China is community embedded elderly care. This embedding is not only geographical but also involves the embedding of real needs, facility resources, diverse entities, and value concepts. Community embedded elderly care is not only a necessary path to achieve the goal of ensuring that all elderly people enjoy basic elderly care services but also a key direction and inevitable trend for the future development of modern elderly care models in China.
To this end, governments, communities, enterprises, and social organizations should further clarify their respective主体 responsibilities, combine regional characteristics, rely on favorable resources, and work together to promote the high-quality development of community embedded elderly care. Specifically:
First, for local governments, efforts should be made to try to change traditional governance concepts and methods, encouraging more market and social entities to participate in the supply of elderly care services. At the same time, it should be clearly recognized that the主体 responsibility borne by themselves in the development of elderly care services cannot be ignored. Promoting community embedded elderly care cannot be separated from the policy support and publicity guidance of the government, and the operation of community embedded elderly care cannot be separated from the overall coordination and supervision management of the government.
Second, for grassroots communities, they should always fulfill the purpose of serving the residents, continuously improve the management service system within the community, actively link various elderly care service resources based on the elderly people’s needs, and enhance the public service capacity of grassroots communities.
Finally, for enterprises and social organizations, service orientation should be standardized, and operations should be managed properly. The elderly care service industry itself has certain public welfare attributes. Therefore, whether it is public-private cooperation or market-oriented operation, operators should adhere to the principle of unifying economic and social benefits, working in the same direction as the government’s intention to develop community embedded elderly care.
So, what specific ways or means can we use to achieve the goal of high-quality development of community embedded elderly care? Based on the multi-dimensional embedding issues mentioned above, the following four suggestions are proposed:
First, strengthen the construction of information platforms and optimize the service supply structure. Building and maintaining elderly care service information platforms is aimed at more timely, comprehensive, and accurate grasping of the real elderly care service needs in the community. Therefore, a long-term perspective and pragmatic attitude should be adopted to strengthen the construction of information platforms, striving to do the “basic work” well in hardware facilities, data collection, information processing, etc., and truly implement the demand linking mechanism for elderly care services in the community. On this basis, service suppliers should also integrate social resources in a targeted manner based on their understanding of the actual elderly care service demand situation, timely adjusting the relevant elderly care service projects to further optimize the service supply structure of community embedded elderly care.
Second, improve the working environment for frontline personnel and enhance talent team construction. On one hand, under the premise of ensuring that the work content and intensity remain largely unchanged, gradually improve the salary and welfare levels of frontline personnel, paying attention to the physical and mental health of grassroots employees, and create a good and comfortable working environment to achieve the dual goals of reducing the turnover of frontline personnel and stimulating employees’ enthusiasm for work. On the other hand, the government and social operators should gradually deepen cooperation with local vocational high schools, colleges, and research institutes, actively exploring the integration mechanism from “talent cultivation” to “talent delivery” through establishing professional internship points, building practical teaching bases, and signing targeted employment agreements to optimize the structure of the elderly care service talent team.
Third, consider the needs of multiple parties and refine support policies. The sinking of quality elderly care service resources relies on the overall planning of the government, support from communities, participation from society, and recognition from the public. Therefore, during the process of developing community embedded elderly care, it is necessary to fully listen to the demands of multiple parties, consider the rights and interests of both public and private sectors, and actively explore cooperation mechanisms for joint discussion, construction, and sharing, breaking down the information barriers in the multi-party coordination process to better eliminate institutional barriers in facility construction operations and elderly care service supply. In addition, local governments should also refine and implement relevant support policies for community embedded elderly care based on actual conditions, such as simplifying approval processes, providing tax benefits, expanding activity funds, and assisting in resource linking, ensuring that relevant government funds can be disbursed on time and in full.
Fourth, rely on local resource conditions and explore more embedding models. Community embedded elderly care does not have a fixed paradigm. Blindly copying the development models of Shanghai, Beijing, and other places and using “urban thinking” to develop rural areas, or using “plain thinking” to evaluate mountainous areas will likely result in “incompatibility.” In fact, the key to developing community embedded elderly care is to grasp the core, take root in the local area, and adapt to local conditions. Localities should fully utilize their advantageous resource conditions (such as land, funds, talents, markets, cultures, etc.), pay attention to the sinking and integration of resources, and explore development paths for embedded elderly care that align with local realities, such as rural communities in Datong City independently building nursing homes relying on village collective economies and the Charity Association of Yanchuan County raising funds to build Happy Homes throughout the county.
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