The Integrated Nursing and Care Service Program (INCSP)
Seoul Metropolitan Government

A. Problem Analysis

 1. What was the problem before the implementation of the initiative?
Before the Seoul Metropolitan Government (SMG) introduced the Integrated Nursing and Care Service Program (INCSP, formerly known as the Patient Reassurance Hospitals Program or PRHP), it was largely up to the spouses or immediate family members to nurse and care for bedridden loved ones in Korean hospitals (72.9 percent, Korean Health & Medical Workers’ Union Survey 2010). Between 2000 and 2010, however, the number of single-person households grew by 86.2 percent, while the elderly population grew by 60.9 percent and the number of working women also grew by 12.7 percent. Despite these sweeping and rapid changes in family and social structures, however, caring for the ill in the hospital in Korea still remained the job of family members and private services. In such circumstances, when a family member fell ill, people had either to take time off work, quit their jobs or spend approximately KRW 2.4 million on average per month to hire private nurses and caretakers. The prevalence of under-qualified private nurses also increased various health risks for patients, including infection, and there were chronic shortages of nurses and caretakers prepared to handle emergency situations. Constituents everywhere in Korea were therefore greatly interested in addressing this policy issue, as 69 percent of patients in need of nursing had a monthly average household income of less than KRW 2 million, while 85 percent of families caring for ill family members found it difficult to afford private nursing. Interest was especially high among middle-aged couples in their 50s or older, two-person households, and low-income households. In response to the rising social demand for a paradigm shift in nursing and care services, the SMG finally launched the INCSP, trialing it first at the Seoul Medical Center, a public hospital

B. Strategic Approach

 2. What was the solution?
First, the INCSP incorporated nursing and caretaking, formerly thought of as private matters, into the concern of the public health insurance system. Second, the INCSP provided universal nursing and care services for all citizens in need. Third, the INCSP allowed participating hospitals to select and hire qualified nurses and caretakers, which better ensured the quality of services provided

 3. How did the initiative solve the problem and improve people’s lives?
The INCSP most importantly alleviated the financial burden borne by family members compelled to care for ill family members. Hiring private nurses and caretakers used to cost KRW 80,000 a day or KRW 2.4 million a month on average. The INCSP, on the other hand, allowed families to receive quality nursing and care services for a flat monthly cost of KRW 450,000. This represented an astounding discount. The INCSP has also relieved people of worries about possibly being unable to seek and obtain the care services they might need in the future. The elderly and single-person household population in Korea is growing rapidly, while more and more women are joining the workforce. This social trend has left many middle-aged and elderly people worrying that they might be without help, in the absence of a social security system, if they fell ill and became bedridden. With the INCSP, however, caring for the ill has become a societal and public issue rather than a family or private one. Patients also express great satisfaction with the quality of nursing and care services they have received from the program. The program has reduced the number of patients per nurse from 17 to seven, and it provides professional nurses and caretakers on standby 24/7 to prevent medical accidents and handle emergency situations competently.

C. Execution and Implementation

 4. In which ways is the initiative creative and innovative?
The INCSP has transformed the nature of professional nursing and care services from private services procured by individuals into quality public healthcare in public hospitals fulfilling their social missions. The transformation of private nursing and care services into a universal public healthcare system has also significantly reduced the financial burden on individual families, while improving the quality of nursing and care services overall and creating additional jobs for locals. The SMG’s program has also inspired the Ministry of Health and Welfare (MOHW) to include integrated nursing and care services run by local governments into the National Health Insurance scheme, thus reducing the financial burden not only for patients and families, but also for local governments across Korea.

 5. Who implemented the initiative and what is the size of the population affected by this initiative?
In March 2012, the SMG organized discussions with healthcare and welfare experts on the INCSP. The advisory board assembled held three plenary meetings to conduct the systemic and thorough preparations necessary to arrive at an appropriate program. The program, which started with 180 beds at the Seoul Medical Center in 2013, quickly expanded its scope to 380 beds in 2014, 555 beds in 2015, and 687 beds in 2016, with five hospitals participating (the Seoul Medical Center, Seoul Metropolitan Dongbu Hospital, Seoul Boramae Medical Center, Seonam Hospital, and Bukbu Hospital). The number of patients benefitting from the program has also been increasing rapidly, from 66,368 in 2013 to 122,975 in 2014, 163,811 in 2015, and 187,130 in 2016. The SMG has made sure that the program spread to other leading hospitals across the nation by sharing the successes and lessons of its program with 137 medical institutions, including Seoul National University Hospital and the Samsung Medical Center, over the past four years.
 6. How was the strategy implemented and what resources were mobilized?
Initially, the SMG organized advisory board meetings to discuss and prepare for the PRHP (which became the INCSP later). In January 2013, the Seoul Medical Center became the first hospital in Korea to provide integrated nursing and care services. To ensure the successful establishment of the program, the SMG organized 15 volunteers to assist in the Seoul Medical Center PRHP Support Group. The scope of the INCSP, which began with 180 beds at the Seoul Medical Center in 2013, rapidly expanded to 380 beds in 2014, 555 beds in 2015, and 687 beds in 2016, with five hospitals participating (the Seoul Medical Center, Seoul Metropolitan Dongbu Hospital, Seoul Boramae Medical Center, Seonam Hospital, and Bukbu Hospital). In 2013, the SMG provided a total of KRW 3.6 billion to subsidize the program at the Seoul Medical Center, supporting 107 staff members and 180 beds with patients. This undivided attention and support helped the program become a success early on. As of 2016, the SMG had invested a total of KRW 20.948 billion in the program (with KRW 6.051 billion drawn from the national treasury and the remaining KRW 14.897 billion from the city’s budget). The SMG continues to monitor the program, including the number and arrangement of professional caretakers, the number of benefitting patients, and the patients’ satisfaction rates, to ensure its continued success. It was the successes and lessons of the SMG’s initial PRHP that inspired the MOHW to adopt and implement a similar program nationwide in July 2013. By March 2015, integrated nursing services were included in the National Health Insurance scheme. As of December 2015, the SMG’s PRHP was finally merged with the MOHW’s integrated nursing service program to become today’s INCSP. By ensuring the success of the PRHP at the Seoul Medical Center, the SMG successfully reduced the social and economic cost of nursing and caring for bedridden patients, in addition to creating new jobs in the public healthcare sector and instigating the early establishment and growth of the INCSP nationwide.

 7. Who were the stakeholders involved in the design of the initiative and in its implementation?
The Mayor of Seoul, the head of the SMG’s Office of Welfare and Health, the CEO of Seoul Medical Center, and other parties first met in 2012 to discuss launching the INCSP at the Seoul Medical Center. An advisory board was set up afterward, with representatives of not only the city government and Seoul Medical Center, but also those from academia, labor unions, and local NGOs. The members of the board met three times in total to draft and release the Healthy Seoul 36.5 Declaration as part of announcing the INCSP. Once the program was launched, the SMG organized 15 volunteers for its Seoul Medical Center PRHP Support Group to ensure the successful establishment of the program at the hospital. The PRHP was then designated as part of the MOHW’s trial integrated nursing service program in 2014. Under the amended Medical Service Act of 2016, the MOHW’s integrated nursing service program will be implemented in all hospitals by 2018. ※ Advisory Board Membership - Academia: Kim Hyeon-jeong (professor at Korea University), Lee Geon-se (professor at Konkuk University), and Yu Seon-ju (research fellow at the Korea Health Industry Development Institute). - Labor: Hyeon Jeong-hee (vice-chair of the Korean Public Service and Transport Workers’ Union) and Han Mi-jeong (vice-chair of the Korean Health and Medical Workers Union). - NGOs: Ahn Gi-jong (president of the Korea Alliance of Patients’ Organizations), Kim Won-il (bureau head at the Korean Nurses Association), and Choi Gyeong-suk (director at the Korean Nurses Association). - Seoul Medical Center: Song Gwan-yeong (head of the Training and Research Department), Lee In-deok (manager of the Ward Nursing Team), and Cho Gyu-seong (manager of the Planning Team). - SMG: Kim Chang-bo (officer of the Health Policy), Mo Hyeon-hee (head of the Health Policy Division), and Yun Jae-sam (manager of the Health Policy Team).

 8. What were the most successful outputs and why was the initiative effective?
The introduction of the INCSP solved the growing dilemma of the need to provide quality nursing and care for patients, on the one hand, and the rapid social changes that made it impossible for families to provide care, on the other. The program brought nursing and care services into the domain of public healthcare. In doing so, it has achieved a fundamental paradigm shift on nursing and care services and the role of public hospitals in Korea. The incremental expansion of the program over the years has also significantly reduced the financial burden on families. Now that the INCSP is paid for, in part, by the National Health Insurance scheme, each family need only pay KRW 450,000 a month, a mere tenth of the cost previously, to ensure quality care for ill family members. The program has also increased the availability of professional nurses and caretakers for patients, dramatically improving the quality of nursing services. Finally, the program induced the national government to amend the Medical Service Act (by newly inserting Paragraph 2 into Article 4, effective as of September 30, 2016) so that patients everywhere in Korea could enjoy the same quality services

 9. What were the main obstacles encountered and how were they overcome?
The INCSP is centered on providing quality and advanced nursing and care services thought having professional caretakers on standby 24/7. Initially, it was difficult to recruit the number of competent and talented professional nurses and caretakers needed. The program developers thus worked hard on finding and developing a fair remuneration system and ensuring suitable working conditions for professional nurses and caretakers. It was also important for the city to find adequate fiscal resources for the hiring of additional nurses and caretakers and providing them with the necessary equipment. Participating hospitals have set up residences for professional nurses and caretakers, provided financial aid for their continuing education at universities, and introduced a series of other welfare benefits, with the fiscal support from the SMG.

D. Impact and Sustainability

 10. What were the key benefits resulting from this initiative?
The INCSP turned nursing and care from a family matter into part of the public healthcare system, thus drastically reducing the financial burden on patients and families, while also ensuring quality nursing and care for all patients hospitalized at five municipal hospitals (the Seoul Medical Center, Dongbu Hospital, Boramae Medical Center, Seonam Hospital, and Bukbu Hospital), with professional nursing staffs on standby 24/7. Moreover, the INCSP of Seoul successfully induced the national government to introduce its own integrated nursing service program, allowing patients across the whole nation to enjoy similar benefits. The SMG equipped participating hospitals with medical devices (wheelchairs, special beds, etc.) and facilities (special bathrooms and fitting rooms) to cater to the physically disabled. It also created women-only wards and treatment rooms, all in an effort to ensure equal access for everyone to quality care. Citizens picked the INCSP as the SMG’s best policy program at the 2013 Hope Seoul Policy Fair, and patients who participated in the satisfaction survey gave the program a high score of 92 percent in 2016.

 11. Did the initiative improve integrity and/or accountability in public service? (If applicable)
The SMG’s INCSP has been popular with the public since its introduction. It was selected by citizens as the best policy program at the 2013 Hope Seoul Policy Fair, ranked fourth place among the top 10 news issues of 2013, and was covered in major newspapers over 200 times. The INCSP has significantly alleviated the financial and psychological burdens on families having to look after their ill family members. It has also reduced the number of patients per nurse from 17 to 7, making it possible for nurses to provide quality care on a par with their counterparts in other advanced countries, such as the United States and Japan. Prior to the introduction of the program, caring for bedridden family members would wreak havoc on family finances due to the high cost of not only medical services, but also the hiring of private nursing care. Often, at least one of the family members would be forced to take time off work or quit their job to dedicate themselves entirely to caring for their ill loved one. The family caregiver, in the process, would sometimes also fall ill. Otherwise, families had to rely on cheaper under-qualified caretakers in whose care patients’ conditions might worsen. Under the INCSP, by contrast, professional nurses and caretakers perform professional nursing services around the clock—such as administering injections, checking up on and readjusting respiratory aids, changing patients’ dressings, and tending to patients’ bedsores—and help patients with other tasks for personal hygiene, eating, and exercising. Hospital orderlies also assist nurses and caretakers to provide quality care for patients and families alike. All these changes have enhanced the public’s trust in the SMG’s administration. In May 2016, the National Health Insurance Service designated the Seoul Medical Center as an exemplar of integrated nursing services for other public hospitals and healthcare programs to emulate.

 12. Were special measures put in place to ensure that the initiative benefits women and girls and improves the situation of the poorest and most vulnerable? (If applicable)
The INCSP-participating hospitals in Seoul provide women-only wards and rooms so that women patients can receive care in a more comfortable and private environment. The program assigns female nurses only to these women patients. The program also provides free nursing and care services for homeless patients, elderly patients without family members, and terminal-stage cancer patients, helping with personal hygiene, bathing, and assisting them to eat.

Contact Information

Institution Name:   Seoul Metropolitan Government
Institution Type:   Local Government  
Contact Person:   Jaeyeon Oh
Title:   Health Care Policy Division  
Telephone/ Fax:   +82-2-2133-7515
Institution's / Project's Website:  
E-mail:   yeon6999@seoul.go.kr  
Address:   110,Sejong-daero, Jung-gu
Postal Code:   04524
City:   Seoul
State/Province:  
Country:  

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