康复和老年医疗联络服务(RALS)的作用.ppt

Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,*,Dr Helena Ng,Consultant Geriatrician,Rehabilitation and Aged Liaison,Service,13 June 2010,Improving the Care of Older People in General Medical Units and their transition into the Sub-acute programme the role of the Rehabilitation and Aged Liaison Service(RALS),改善普通病房老年患者的服务,并改善与亚急性服务的衔接,康复和老年联合服务项目的作用,Introduction to RALS,康复和老年联合服务项目简介,The Rehabilitation and Aged Liaison Service(RALS)provides specialist geriatric,senior allied health and nursing staff input in the assessment and management of older patients in the General Medical Units and assists with their transition into sub-acute care.,It forms an integral part of the General Medical multi-disciplinary team.,The service was established in April 2008 at Monash Medical Centre(MMC,Clayton)and commenced in May 2009 at Dandenong Hospital.,康复和老年联合服务项目,(RALS),是老年医学专家、老年人联合服务人员、护理人员等在普通病房给老年患者提供病情评估和疾病管理服务，并帮助老年患者转到亚急性服务,RALS,在普通病房建立多学科团队,蒙纳仕大学医学中心在,2008,年,4,月开始这项服务，,2009,年,5,月在丹迪农医院开展这项服务,The RALS team,康复和老年年和服务的团队,General Medicine RALS clinician(liaison position),Full time,Social worker(Monash Medical Centre),Occupational therapist(Dandenong Hospital),Geriatrician,Part time,2 Geriatricians at Monash Medical Centre,1 Geriatrician at Dandenong Hospital,1 full time Geriatric trainee at Dandenong Hospital,Manager,普通病房的,RALS,医师（联合位置）,全职,社会工作者（蒙纳仕医学中心）,功能康复师（丹迪农医院）,老年医学专家,兼职,蒙纳仕医学中心,2,人,丹迪农医院,1,人,丹迪农医院,1,名老年医学学员,管理人员,What is the role of RALS?,康复和老年联合服务项目的任务,Improve the model of care and clinical outcomes for older general medical patients.,Reduce multiple assessment steps by completing required assessments.,Improve continuity of patient care from acute(hospital)to sub-acute(hospital and community)programmes or services.,Improve communication between patients,their families and the medical teams.,Improve understanding of and patient access to available sub-acute services.,改善普通病房老年患者的照顾模式，并改善他们的健康结果,对所需要的各种检查要求，减少重复检查步骤,改善从急性服务（医院）到亚急性服务（医院与社区）的连续性,改善患者、家庭、医务团队之间的沟通,提高对亚急性服务的了解，并提高对亚急性服务的可及性,What does RALS do?,康复和老年联合服务的工作,Attend daily multi-disciplinary meetings.,Work closely with the treating team to optimise patient management.,Provide advice and support on discharge planning.,Conduct assessments previously requiring an additional assessment service.,Information resource.,Provide specialist Geriatric opinion.,Gate-keeper.,参加每天的多学科会议,与治疗团队密切合作，优化对患者的诊治,为出院计划提供建议和支持,在提出额外检查服务之间，对患者进行评估,提供信息服务资源,提供老年医学专家的建议,守门人,Patient review,对患者的评估,Average of four new patients per day*.,Average of six patients seen per half day,(range 2 12).,Reason for RALS review:,Opinion or advice on diagnosis or management,Prevent functional decline,Discharge planning,Rehabilitation,Residential Care(Aged Care Assessment),*Data for Monash Medical Centre Rehabilitation and Aged Liaison Service.,平均每天对四名新患者进行评估,*,平均每半天看六个患者（范围,2-12,名患者）,开展,RALS,患者评估的原因,:,对诊断或治疗提出观点或建议,预防功能衰退,出院计划,康复,老年照护机构的服务（老年保健评估）,Patient review an example,对患者的评估,举例,90 year old man living alone,admitted after a fall.Becomes increasingly confused and is very agitated and disruptive overnight.,RALS asked to review behaviour management.,Recognition&assessment of delirium,Education on management of delirium including changing exacerbating medication(s),Preventing complications,Preventing decline in function,90,岁男性老人，独住，跌倒后入院。患者越来越糊涂，夜间严重焦躁不安，具有破坏性,需要,RALS,对患者的行为治疗进行评估,确认和评估是否存在精神错乱,进行有关精神错乱治疗的教育，包括更换那些使病情加重的药物,预防并发症,预防功能减退,Sub-acute programme,亚急性服务计划,Inpatient rehabilitation,Geriatric Evaluation&Management,Casemix Rehabilitation&Funding Tree,(general or specific rehabilitation),Community rehabilitation,Rehabilitation In The Home,Community Rehabilitation Centre,Outpatient rehabilitation,住院康复,老年医学评价和治疗,病例组合的康复和费用支付分类（普通康复和专科康复）,社区康复,居家康复,社区康复中心,门诊康复,Sub-acute programme,亚急性服务计划,Transition Care Programme,Residential,Community(home-based),Aged Care Assessment Service,Community Aged Care Packages,Respite,Residential Aged Care,服务衔接计划,机构照护,社区照护（以家庭为基础）,老年保健评估服务,社区老年照顾服务包,暂缓,老年照护机构的服务,Assessment form,评估表格,Why is this model better?,这种模式的优点,Better relationship with treating medical team.,Better acceptance of advice.,Better understanding of rehabilitation and other sub-acute services.,Minimise complications of hospitalisation in elderly.,More rapid transition to rehabilitation.,Fewer medically unstable patients transferred to rehabilitation.,Fewer assessment steps.,与治疗团队建立更好的关系,提出的建议更容易得到接受,对康复和其他亚急性服务有更好的理解,使老年人住院并发症最少化,更快地衔接到康复服务,避免医学情况不稳定的患者转到康复服务,减少评估的步骤,Summary,小结,In summary,the Rehabilitation and Aged Liaison Service plays an important role in improving the management of older General Medical patients and ensuring a smooth transition for patients and their families into the sub-acute care programme.,总而言之，康复和老年联合服务（,RALS,）在改善普通病房住院的老年人的老年医学服务方面发挥着重要的作用，它还可以保证患者和家属顺利地从急性服务转到亚急性服务,Acknowledgments,致谢,RALS,临床医师,Devereaux De Silva,Sarah Bright,老年医学专家,Dr Julie Lustig,Dr Irene Wagner,康复和老年服务项目医学主任,巴巴拉 沃克曼教授,服务的获得和重组项目主任,Carolyn Flower,服务的获得和改进项目主任,Brydie Quinn,