澳大利亚的老年康复医学进展.ppt

Geriatric Rehabilitation in Australia Model of Care and Funding Arrangements澳大利亚老年康复医学 服务和筹资模式Professor Barbara Workman 巴巴拉沃克曼教授Professor of Geriatric Medicine 老年医学教授Medical Director Rehabilitation and Aged Services 康复和老年服务项目医学主任Director of Monash Ageing Research Centre 蒙纳仕老年研究中心主任12 June 2010AUSTRALIA/CHINA澳大利亚与中国澳大利亚与中国Land mass and demographics国土和人口Area(sq km)国土Population 人口 65 years in 201065岁及以上老年人 65 years in 2050(projected)预计2050年65岁及以上老年人China中国Australia澳大利亚9,596,9607,682,3001.3 billion22 million102 million 2.9 million8%14%322 million 9 million24%23%Demographics人口学Source:Australian Bureau of Statistics(2005)资料来源：澳大利亚统计局Source:World Population Prospects(2005)资料来源：世界人口展望CHINA中国中国AUSTRALIA澳大利亚澳大利亚AUSTRALIA澳大利亚澳大利亚北领地北领地昆士兰昆士兰南澳南澳西澳新南威尔士新南威尔士塔斯玛尼亚塔斯玛尼亚维多利亚维多利亚首都领地首都领地Southern Health catchment南区卫生服务集团覆盖区域南区卫生服务集团覆盖区域Aerial view of Monash Medical Centre蒙纳仕医学中心鸟瞰蒙纳仕医学中心鸟瞰Main entrance Monash Medical Centre蒙纳仕医学中心大门蒙纳仕医学中心大门 Kingston CentreOriginal buildingFront entrance to Dandenong HospitalKingston Centre in 2012金士顿中心，2012年 Perspective view looking north east from Warrigal Road Artists impression 从从Warrigal路向东北看路向东北看Aged Rehabilitation selection老年康复 选择Patients are selected for rehabilitation according to need for restoration of functionAssessed by a Geriatrician or Rehabilitation ConsultantThey may be accepted toinpatient rehabilitation community rehabilitation Community Rehabilitation Centre(CRC)Rehabilitation in the Home(RITH)Outpatient Rehabilitation根据功能恢复的需要，来选择接受康复服务的患者由老年医学专家或康复专家来评估患者可以接受住院康复 社区康复 社区康复中心(CRC)居家康复(RITH)门诊康复Aged Rehabilitation Selection老年康复 选择Must be predominantly medically stableMain goals for rehabilitation must be stated at the time of assessmentThe person must have the potential to become independent and return to their homePeople requiring residential care or long term care are not accepted to a rehabilitation bed even as an interim measureThere are two funding options for aged rehabilitation in hospital with slightly different acceptance criteria必须明显地处于医学上的稳定状态评估时必须明确康复的目标患者必须有可能恢复独立，返回家庭康复病床不接受照护机构服务或长期保健服务根据接收标准，有两种针对老年康复的付费方式Aged Rehabilitation Selection老年康复 选择Geriatric Evaluation and Management(GEM)More medical managementChronic medical conditions that require stabilization Allow time for evaluation of whether a person will manage at homeOften managed by a GeriatricianAn example may be recovery following pneumonia in a person with chronic airways disease who is oxygen dependant and has poor mobility老年医学评价和治疗(GEM)主要侧重于医学治疗需要稳定病情的慢性疾病需要花时间进行评价，即便患者在家治疗经常由老年医学专家来管理举例：肺炎后的恢复过程，该患者有慢性呼吸道疾病，依赖氧气，行动困难Aged Rehabilitation-SelectionCasemix Rehabilitation and Funding Tree(CRAFT)More physical therapyOften a single medical problemUsually shorter length of stayOften more predictable length of stayOften managed by a Rehabilitation PhysicianAn example may be rehabilitation following total knee replacement in a person who is otherwise well病例组合的康复和付费分类(CRAFT)主要侧重于物理治疗通常针对患者的一个疾病通常是短期住院往往能预测患者的住院天数通常由康复医师来管理举例：全膝关节置换术后的患者，该患者其他方面很健康Aged Rehabilitation Patient Focused老年康复 以病人为中心Information about rehabilitation is provided to the patient at assessmentTransfer to the rehabilitation facility usually occurs within 1-2 daysOnce in the rehabilitation facility patients are expected wherever possible to be out of bed and dressed in normal clothesPatients are expected to work with the staff to agree on their goals for management在评估病人的时候，提供有关康复的信息通常在1-2天内把患者转道康复机构一旦患者进入康复机构，希望患者尽早离开病床，自己穿衣服希望患者和工作人员一起合作，对康复目标达成共识Aged Rehabilitation Multidisciplinary team老年康复 多学科团队Each patient will have their own Doctors,and allied health staff throughout the admissionEach staff member will assess the patient and work with the patient to determine the goals for rehabilitation within 1-2 days of admissionIt is routine for all patients to be seen by a physiotherapist and occupational therapist每个患者住院期间，都有他们自己的医生和辅助性的卫生服务人员患者入院后1-2天内，每个员工都要评价患者，和患者在一起确定康复目标作为常规，所有患者都要接受物理治疗和功能治疗专家的服务Aged Rehabilitation Multidisciplinary team老年康复 多学科团队Patients are only seen by speech pathologist,social worker,dietitian and psychologist if there is a need for these interventionsA member of staff is allocated as the Key Liaison Person(KLP)to ensure consistent communication with the patient and family The KLP can be from any health discipline如果需要的话，病人可以接受语言治疗师、社会工作者、营养师、心理医师的服务专门设置关键协调人（KLP）来保证与患者和家人的持续沟通关键协调人可以是任何卫生工作者Aged Rehabilitation Multidisciplinary team老年康复 多学科团队Example of staffing in a rehabilitation ward of 30 beds with neurological rehabilitation举例：神经康复科30张病床病房的人员配置EFT(employed full time)全职工作岗位Medical consultant 医师 0.3-0.5 Registrar 学员1HMO/intern 住院医师1Nurse:patient 护士：患者1:5 am,1:6 pm,1:10 overnight Physiotherapist 物理治疗师3 Occupational therapist 功能治疗师2.5 Speech pathologist 语言治疗师1Dietitian 营养师0.7Clinical psychologist 临床心理师 0.2Neuropsychologist 神经心理师 0.3Social worker社会工作者1.8 Allied health assistant 辅助卫生人员2Aged Rehabilitation Multidisciplinary team老年康复 多学科团队Medical problems eg control of diabetes,airways disease,angina,wound,poly-pharmacyPhysical function walking,gait aid,balance,stamina Self care bathing,dressing,cooking,shoppingNutrition current status,access to foodSwallowing and speech in the context of stroke or other neurological rehabilitationCognition delirium/dementia,brain injuryMood depression/anxiety/other mental health issuesHome environment and services includes ability to continue driving医学问题 如控制糖尿病、呼吸道疾病、心绞痛、外伤、使用多种药物躯体功能 走路、助步器、平衡、耐力自我照顾 洗澡、穿衣、做饭、购物营养 目前状况、获得食物吞咽和说话 与中风或其他神经康复有关认知 精神错乱/老年痴呆、脑损伤心情 抑郁、焦虑/其他心理健康问题家庭环境和服务 包括继续开车的能力Patient being assisted to learn how to drink following a stroke 工作人员帮助中风后患者学习喝水工作人员帮助中风后患者学习喝水Aged Rehabilitation Multidisciplinary team老年康复 多学科团队Daily ward round with Registrar and HMO/InternTwice weekly ward round with ConsultantDaily brief meeting(30 minutes)of staff for update on progress for each patientDaily therapy with main allied health staff,other staff as neededWeekly Team MeetingFamily meetings occur as needed with complex discharge planning学员和住院医每天查房医学专家每周两次查房员工每天30分钟例会，更新每个患者的情况辅助卫生工作者每天进行治疗服务每周团队例会如果是比较复杂的出院计划，请家属开会Aged Rehabilitation Multidisciplinary team老年康复 多学科团队Weekly Team Meeting plan treatment estimate date of discharge documentation of goalsmajor decision making requiring full team contributionmonitoring progress towards achieving goalssharing informationplanning for dischargeGoal setting documents are completed at the Team meeting and a copy is provided to the patient and family每周团队例会 制定治疗计划 估计出院日期 撰写治疗目标需要团队全体人员参与的决定监测达到目标的进展分享信息制定出院计划在团队会议上完成目标文件，并将文件副本交给病人和家属Aged Rehabilitation-Goal Oriented老年康复 目标管理Aged Rehabilitation Multidisciplinary team老年康复 多学科团队After the team meeting the KLP will communicate with the patient and family in person,by phone or in writingKLP is the person who does any negotiating for the team with the patient and familyFamily meetings are held to discuss major decisions or if further planning requires contribution from the family团队会议后，关键协调人(KLP)将与病人和家属联系，通过减免、电话或书信联系关键协调人负责团队与患者和家属的任何协商事宜家属会议的目的是讨论任何主要的决定；或者有进一步的计划，需要家属参与Aged Rehabilitation Patient Focused老年康复 以患者为中心Rehabilitation is provided on the ward in specially designed therapy areas in most of our wardsSome wards have a larger therapy area which is shared with another service and is located outside the ward areaEach therapy space has the equipment needed to provide the rehabilitation for their patient groupEquipment will vary depending on the predominant type of rehabilitation performed in the ward,such as stroke or neurological injury or joint replacement在我们大多数的病房里，康复服务是在病房里进行的、专门设计的治疗服务有些病房有较大的治疗区域，可以与其他服务同时进行，并在病房以外的区域进行每个治疗地点都配备必要的设备，给患者提供康复服务配备的设备主要是根据该病房的患者的康复需要，比如中风、或者神经损伤，或者关节置换Aged Rehabilitation Patient Focused老年康复 以患者为中心Aged Rehabilitation Therapy Area老年康复 治疗区域Aged Rehabilitation Patient Focused老年康复 以患者为中心Discharge planning commences at admissionPlan for where the patient will be discharged to and what they will need to support themGoals determined are based on what will be needed for the patient to be able to manage at place of discharge complete return to previous function is not always necessary for discharge as rehabilitation can continue in the communityPlans may include a period of inpatient rehabilitation followed by a period of rehabilitation with either CRC or RITH在患者入院时，就开始制定出院计划出院计划涉及到患者出院后到什么地方，出院后需要哪些支持出院计划的目标，是根据患者出院后的需要而定的。在出院时几乎不可能完全恢复到原来的功能状态，患者在社区里还可以继续康复出院计划可以是一段时间的住院康复，然后接着社区康复中心或老年照护机构的康复Aged Rehabilitation Patient Focused老年康复 以患者为中心Discharge includes making arrangements for whatever services are needed to enable the patient to manage at homeServices after discharge may include,meals on wheels,personal care assistance,aged care packages,district nursing,socialization groups,home modifications,transport for appointments,home help for cleaning and laundry,assistance with shopping出院计划要包括患者需要的任何服务，以保证患者在家休养出院后服务可以包括送饭服务、个人保健辅助服务、老年照护服务计划、地段护士服务、社会化小组服务、居家条件改造服务、复诊的交通服务、家务帮助服务如清洁和洗衣、购物帮助服务等Graph of Length of Stay(LOS)in days住院日（天）亚急性住院科室 总计 2009 2010 GEM-老年医学评价和治疗CRAFT 病例组合的康复和付费分类Aged Rehabilitation Funding老年康复 筹资方式Public rehabilitation is fully funded by the State Governments州政府负责全额支付公立的康复服务GEM 老年医学评价和治疗Funded at$522/day for each day the patient is in hospital 患者每住院一天，政府支付给522澳元CRAFT 病例组合的康复和付费分类Casemix funded according to diagnosis 根据诊断，按照病例组合的规定来支付Based on average cost for the diagnosis 根据诊断的平均成本来计算The patient may be required to fund some equipment and home modifications on discharge 可能在出院的时候让患者支付一些设备费用和居家条件改造费用Aged Rehabilitation CRAFT FundingNext slide is the translation Aged Rehabilitation CRAFT Funding老年康复 病例组合的康复和付费分类所有病例所有病例 10,238中风中风/神经学疾病神经学疾病 n=2,632 骨科骨科/整形疾病整形疾病 n=4,112 心脏心脏/肺部疾病肺部疾病 n=579 截肢截肢 n=515 头部损伤头部损伤/外伤外伤 n=154 脊柱损伤脊柱损伤 n=122 烧伤烧伤 n=21 其他其他 n=2,103 低入院评分低入院评分高入院评分骨折骨折髋髋/膝关节置换膝关节置换其他其他低入院评分低入院评分高入院评分低入院评分低入院评分中入院评分中入院评分高入院评分高入院评分低入院评分低入院评分高入院评分高入院评分低入院评分低入院评分高入院评分高入院评分Aged Rehabilitation CRAFT Funding老年康复 病例组合的康复和付费分类VicRebab病房：病房：2003-04康复权重康复权重CRAFT分类 界内高值 界内低值 平均住院日 当日住院权重 短期住院权重 低界外值 界内权重 高界外值 短住院中风/神经 低评分中风/神经 高评分骨折 低评分骨折 高评分置换 低评分置换 中评分置换 高评分其他骨科 低评分其他骨科 高评分心肺其他 低评分其他 高评分Aged Rehabilitation CRAFT Funding老年康复 病例组合的康复和付费分类http:/www.health.vic.gov.au/casemix/康复病例的分布范围康复病例的分布范围低界外值高界外值界内值（平均住院日加减4天）低界内点 平均住院日 高界内点Aged Rehabilitation in the community老年康复 社区内康复Community Rehabilitation Centre(CRC)Patients live at home and attend the centre several times per week for 2-4 hoursThe CRC is staffed with allied health who develop a therapy program and see the patient each visitThe Doctor will attend the CRC weekly and patients will be booked for review 1-2 times during the time of attending in the CRCAttendance at the CRC will usually not continue for longer than 8-12 weeks.社区康复中心(CRC)患者住在家里，每周分几次来社区康复中心2-4小时社区康复中心配备辅助卫生工作者，他们负责制定治疗计划，并为患者提供服务医生每周来社区康复中心，患者可以在社区康复中心预约1-2次的医生服务一般来说，在社区康复中心接受的服务不会超过8-12周Aged Rehabilitation group in CRC老年康复 社区康复中心的患者小组 Aged Rehabilitation outpatients老年康复 门诊康复Outpatient rehabilitationMore intensive therapy than at CRCThe patient lives at home but attends the CRC 5 days per week and spends up to 6 hours in therapyOutpatient therapy is often performed by the same therapists who cared for the patient in hospitalThe model is for multidisciplinary management of the patient门诊康复服务与社区康复中心相比，门诊康复包含更多的集中性治疗患者在家里住，但每周5天来社区康复中心，接受6个小时的治疗提供门诊治疗的治疗师，往往就是在医院给患者治疗的同一个人这个模式，是给患者提供多学科的服务Aged Rehabilitation outpatients老年康复 门诊康复Aged Rehabilitation RITH老年康复 居家康复Rehabilitation in the Home(RITH)Patients will go home and allied health staff will visit and treat in the home 2-3 times per week for 1-2 hours.Usually physiotherapy but may be occupational therapy,speech therapy,social work or dieteticsPatients usually need to be living with someone who can assist them while they regain their independenceThe home needs to be suitable for a person with some disability居家康复(RITH)患者在家里住，辅助卫生工作者每周家访2-3次，提供1-2个小时的服务通常是物理治疗师，但也可以是功能治疗师、语言治疗师、社会工作者，或者营养师患者通常需要与照顾他们的人在一起住，并重获独立能力有一定残疾的人，需要一个稳定的家庭 Aged Rehabilitation RITH老年康复 居家康复Aged Rehabilitation funding of community rehabilitation 老年康复-社区康复的付费CRC,RITH and outpatients are all funded under the Sub-acute Ambulatory Care Services(SACS)system Funding is based on number of contacts with health professionalsThe Health service negotiates with the Government each year for the types of services to be provided and the number of face-to-face contacts by health professionals which will be provided and a block of funding is suppliedThe funding covers cost of staff,premises,cars and travel and all consumables.The Health Service determines the health disciplines to be employed by the funding within each type of services亚急性流动服务计划（SACS）支付社区康复中心、居家康复、门诊康复的服务根据卫生人员的服务次数确定付费数量卫生服务机构每年与政府协商，确定提供服务的种类、给患者提供面对面服务的次数、以及需要政府支付的服务模块付费包括人员费用、合同费、车辆和交通费，以及所有的消耗费用卫生服务机构根据政府投入，来决定各种服务聘用什么卫生专业人员Aged Rehabilitation老年康复Rehabilitation aims to optimize function for older people,maintain independence and quality of life.It is delivered in hospital and in the community and many people have some therapy in both locationsIt is a part of the overall health services provided by the Government in the public health system.康复服务的目的，是让老年人的功能最大化，维持他们的独立性和生活质量康复服务是医院和社区提供的，很多老年人在两个地方得到各种治疗服务康复服务是宏观卫生服务系统的组成部分，它是由政府的公共卫生服务系统提供的Melbourne墨尔本