Gutenbrunner 中徳康复合作领域课件.ppt

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1、Systematic approach to implement rehabilitation in health systems collaboration between China and Germany完成健康体系中的康复医学的系统化处理方法-中德合作Christoph Gutenbrunner,Christoph Gutenbrunner,MD,PhD,Professor Department for Rehabilitation MedicineCoordination Centre for Rehabilitation ResearchHanover Medical School

2、D-30625 Hannovergutenbrunner.christophmh-hannover.de,Overview 内容概要,Arguments:why should we work on the implementation of rehabilitation services?论证：为什么我们应当致力于康复服务的实行？Conceptual approach:how to analyse,plan an implement rehabilitation services 概念性的探讨：如何分析，计划康复服务的实行 Challenges and opportunities:挑战与机遇

3、What are the challenges of planning and implementation projects?计划和和实行方案会有着怎样的挑战 What are the opportunities of collaboration?相互合作会带来什么样的机遇,Arguments:why should we work on the implementation of rehabilitation services?论证：为什么我们应当致力于康复服务的实行？,The International Classification of Functioning,Disability an

4、d Health(2001)国际健康功能与身心障碍分类系统 UN-Convention for the Rights of People with Disabilities(2006)联合国残疾人权利公约 World Report on Disability(2011)世界残疾报告 The“International Perspectives of Spinal Cord Injury”Report(2013)脊髓损伤国际展望报告 Resolution WHA 66.9 Disability“(2013)世界卫生大会66.9号残疾决议 The WHO Global Disability Act

5、ion Plan Better Health for all people with disabilities 2014-2021“(2014)世卫组织20142021年全球残疾问题行动计划：增进所有残疾人的健康,The international“normative”approach国际”标准化“,The UN-CRPD(2006)联合国残疾人权力公约,Article 26:Habilitation and Rehabilitation States Parties shall take effective and appropriate measures,including through

6、 peer support,to enable persons with disabilities to attain and maintain maximum independence,full physical,mental,social and vocational ability,and full inclusion and participation in all aspects of life.To that end,States Parties shall organize,strengthen and extend comprehensive habilitation and

7、rehabilitation services and programmes,particularly in the areas of health,employment,education and social services,()第26条：适应训练和康复缔约国应当采取有效和适当的措施，包括通过残疾人相互支持，使残疾人能够实现和保持最大程度的自立，充分发挥和维持体能、智慧、社会和职业能力，充分融入和参与生活的各个方面。为此目的，缔约国应当组织、加强和推广综合性适应训练和康复服务和方案，尤其是在医疗卫生、就业、教育和社会服务方面,Action Plan:objectives行动计划：三大目标

8、,(1)to remove barriers and improve access to health services and programmes1)清除障碍并提高卫生服务和规划的可及性(2)to strengthen and extend rehabilitation,habilitation,assistive technology,assistance and support services,and community-based rehabilitation(2)加 强和推广康 复、适应训 练、辅助技术、援 助和支持性服务 以及 以社 区为基础 的康复(3)to strength

9、en collection of relevant and internationally comparable data on disability and support research on disability and related services(3)加 强 收集 残疾 方 面 国际上 可对 比的相 关 数 据，并支持关于残疾和相关服务的研究,The WHO Global Disability Action Plan(2014)世卫组织全球残疾问题行动计划,Objective 2:to strengthen and extend rehabilitation,habilitat

10、ion,assistive technology,assistance and support services,and community-based rehabilitation 目标2:加 强和推广康 复、适应训 练、辅助技术、援 助和支持性服务 以及 以社 区为基础 的康复 Action 2.4:Expand and strengthen rehabilitation and habilitation services ensuring integration,across the continuum of care,into primary(including community),

11、secondary and tertiary levels of the health care system,and equitable access,including timely early intervention services for children with disabilities 24扩大并加强康复和适应训练服务，确保 与持续 照护一起纳人初级(包括社区)、二级和三级卫生保健系统，并确保公平获取服务。包括为残疾儿童及时提供早期干预服务,The WHO Global Disability Action Plan(2014),Proposed inputs for Memb

12、er States:Review existing rehabilitation and habilitation programmes and services and make necessary changes to improve coverage,effectiveness and efficiency建议会 员国开展 的工作：审查现有康复规划和服务并作出必要的改变以提高覆盖率、有效性和效率 Proposed inputs for the Secretariat:Support countries in integrating rehabilitation and habilitat

13、ion services into the health system()Develop relevant tools and training packages to develop and strengthen habilitation and rehabilitation services秘书处的工作：支持国家把康复和适应训练服务纳入卫生系统.制定相关的工具和培训一揽子计划，以便发展和加强适应训练及康复服务 Proposed inputs for international and national partners:Work with health ministries to expa

14、nd and strengthen the provision of rehabilitation and habilitation services 建议国 际和 国家伙伴开展 的工 作：与卫生部一起开展工作，推广和加强提供康复服务,Health accounts vs.strategies,In-patient or day clinic rehabilitation for patients with chronic conditions,Levels to describe rehabilitation康复的各描述水平,Macro level宏观水平Meso level中间水平Micr

15、o level微观水平,Health strategy,policy 健康策略及政策,Service provision,concepts 服务分配及慨念,Health condition&functional level(B),Health condition&functional level(A)健康条件及功能水平（A),.,Time,Intensity强度,Acute care急性治疗,Post-acute care急性期治疗,Lon-term care长期治疗,Intermittent rehabilitation(in-patient or day-clinic)间断性康复（门诊或日

16、间诊所）,Post-acurte rehabilitation(in-patient)急性期后康复（住院病人）,Community based rehabilitation(out-patient)以社区为基础的康复（门诊病人）,Acute rehabilita-tion(in hospital)急性康复（院内）,Integrative phase model of rehab care康复治疗的整合分期模式,Gutenbrunner C,Meyer T,Stucki G:Am J Phys Med Rehabil 2011;90:521-525,Level 4:Multi-professio

17、nal rehabilitation services水平4多专业性康复服务,Level 1:families,peers,etc.水平1：家庭，病友等等,Level 3:PRM,specialized PT,OT etc.水平3：康健医学，专业理疗师，职业治疗师等等,Level 2:primary care physicians,PT,OT,etc.水平2：初级护理医生，理疗师，职业治疗师等等,Coordinated referral systems(PRM as advisor and coordinator),PRM delivered servicesPRM as trainer,Le

18、vel 5:highly specialized rehabilitation services(SCI,TBI)水平5高专业化的康复服务（脊髓创伤，脑创伤,Levels of specialization 康康复专业水平,Community Based Rehabilitation基于社区的康复,Gutenbrunner C(2014):submitted,The health systems approach卫生系统探讨,Rehabilitation can be seen as a health strategy it also is described as“a set of meas

19、ures”康复可被视为健康战略也可描述成”一揽子计划”Rehabilitation should be integrated in acute,post-acute and long-term care康复应被整合于急性期,急性期后及长期性治疗中 Rehabilitation should be integrated in primary,secondary and tertiary levels of health care services康复应被整合于医疗服务的一级至三级水平中 Multi-professional rehabilitation services need high st

20、andard of service provision including resources such as facilities,technical equipment and human resources 多专业性康复服务需要高标准的服务供给,包括设施,技术设备及人力资源,The individual approach(examples)病人个人探讨(举例),Patients with long term mechanical ventilation will develop contractures,loose ventilation capacity,develop muscle

21、atrophy,loose circulatory capacity,are in risk of pneumonia and thrombosis and others 机械通气患者常会发展有气管痉挛,肺活量降低,肌肉萎缩,循环血量降低等并发症,处于发生肺炎,血栓及其他的危险下.Patients after stroke will loose opportunity to induce neuroplasticity if rehabilitation does not start immediately after incident 脑卒中病人若在事件后未立即进行康复治疗,神经可塑性引导的

22、可能性讲会降低 Patients with musculo-skeletal pain syndromes are at risk do develop chronic generalised pain syndromes if primary source of pain is not treated sufficiently肌肉骨骼疼痛症患者如疼痛的首因未被有效治疗,将可能发展成为慢性广泛性疼痛综合征.Patients with chronic health conditions are at risk to be unfit for work if rehabilitation is l

23、acking 慢性疾病患者常可被危及无法适应于工作,如果康复医疗缺失的话 Lack of rehabilitation is a health risk,threat to develop disability缺失康复是一个健康风险,甚至可威胁发展至残疾,Economic&development approach(arguments)经济与发展探讨(论证),Lack of rehabilitation increase costs of health care and social compensation,缺少康复会导致健康医疗费用的增长及社会补偿e.g.例如 length of stay

24、in ICUs an in hospital will be longerICU时间将会增加 outcomes of interventions(e.g.surgery)will be poorer 干预手段(如外科手术)的结果变差the prevalence of disability will be higher致残发生率增加 Contribution of individuals to society(and social productivity)will be lower个人对社会(和社会生产力)的贡献减少 Lack of rehabilitation is an economic

25、and developmental risk,e.g.disability without rehabilitation is a burden for health systems Lack of employees(esp.of high education)harms developmental processes缺少康复是一个经济和发展危险因素，例如无康复医疗的残疾会成为卫生系统的负担。缺少被雇佣者（尤其受过高等教育）会损害发展过程 The provision of rehabilitation services may also be a business康复服务的分配也可成为,Co

26、nceptual approach:how to analyse,plan an implement rehabilitation services概念方法：如何分析，计划开展康复服务,Stepwise approach(1)阶梯式方法,Step 1:Agreement on basic principles(e.g.UN-CRPD,WRD,WHA Resolution 66.9,Disability action plan)第一阶段 达成基本共识 Step 2:Analysis of the burden and major causes of disability:第二阶段 残障的主要原因

27、及难点分析 Traffic accidents and other trauma(incl.spinal cord injury,traumatic brain injury,multiple trauma)交通事故及其他外伤 Cardiovascular and metabolic diseases(incl.hypertension,myocardial infarction,diabetes)心血管及代谢疾病 Neurological conditions(including stroke,multiple sclerosis,Parkinsons disease)神经系统疾病 Chro

28、nic musculoskeletal conditions(incl.Low Back pain,osteoarthritis,rheumatoid arthritis,chronic widespread pain and fibromyalgia)慢性运动系统疾病（肌肉骨骼）Paedriatric conditions 儿科疾病 Geriatric conditions(incl.frailty,dementia)老年病,Stepwise approach(2)阶梯式方法,Step 3:Use models of rehabilitation services:第三阶段 使用康复服务模型

29、 Implement rehabilitation along the continuum of care(acute,post-acute,and long term rehabilitation)沿用连续性护理实施康复治疗 Levels of specialization(from acute care to the community)专业化水平 Multiprofessional teamwork as principle of staffing(PRM,PT,OT,SLT,Psychotherapy Social work and others)多专业混合团队协作原则编制人员 Def

30、ined interfaces(incl.transfer systems)界定转诊标准 Create financial system(insurances,states financing or others)建立财务系统 Step 4:Define regions/areas and calculate concrete demand of services 第四阶段 定义区域并估算具体服务需求 Step 5:Mach demand with principles and define concrete plan 第五阶段：以服务需求为原则，并确定具体计划,Level 1a,Level

31、1b,Level 2a,Level 2b,Rehabilitation policy 康复政策,Highly specialized centre,Specialized centre,Rehab centre,Rehab centre,Doctor,PT,OT,S<,others,Peers,families,self-helping groups and others,Level 3,Case management,Levels of care provision 护理级别,高度专科中心,专科中心,康复中心,康复中心,病历管理,同伴，家人，自主互助小组及其他,Example 举例,Ac

32、ute rehabilitation services:in or close to(acute)hospitals 急诊康复-院内或附近 Post-acute rehabilitation services:stand-alone rehabilitation facilities in close cooperation with hospitals(highly specialized and specialized)急诊后康复-独立康复机构-合作医院附近 Long-term rehabilitation service:out-patient or mobile services 长期

33、康复-门诊或随诊 Services for intermittent rehabilitation in chronic conditions:in-patient or day-clinics 慢性病不连贯康复服务-入院或日间诊疗 Vocational rehabilitation services:integrated in rehabilitation and vocational services 职业训练康复服务-康复与职业训练集成的服务 Links to social system:munity and peers 与社会系统连接-比如社区及同伴支持,Definition of s

34、ervices 定义服务,In-patient or day clinic rehabilitation for patients with chronic conditions,Framework of Rehab Services:dimensions康复服务的构架多维度,Service provider:the categories to describe the provider include the framework of the institution(location,organisation etc.)the resources(human and technical re

35、sources)and some aspects of service organisation such as profit-orientation and quality assurance programs.The main questions behind are where and in which context the service is delivered 服务的提供者，最主要的背后问题是在何地，何背景下提供服务 Funding of the service:the categories of funding describe the main sources of inco

36、me and refunding of services.They include the basic principles of payment such as diagnosis-related groups,per-day payment of other forms of service refund.The question behind is what are the principles of financial resources 服务资金来源，背后的问题是融资资金来源问题 Service delivery:the categories on service delivery

37、contain the main strategy applied to the users,aspects of intensity and duration of intervention and the way the service is organised(e.g.team structure).It focuses on the question how the services are delivered to the user 服务提供，关注如何向患者提供服务,Example 举例,Example:Floor plan rehab unit 康复单元平面图,Example:re

38、hab unit(foreground)康复单元（前景）,Time,Intensity强度,Acute care急诊期管护,Post-acute Care后急诊期管护,Lon-term care 长期管护,Intermittent rehabilitation(in-patient or day-clinic),Post-acute rehabilitation(in-patient),Community based rehabilitation(out-patient)基于康复的社交,Acute rehabilita-tion(in hospital),Prevention 预防,Healt

39、hy living(integrated in daily living),Intermittent intensive prevention(in-patient),Integrative phase model of rehab care康复管护的综合阶段模型,间歇强化预防,急诊期康复,后急诊期康复,间歇性康复,Time,Intensity强度,Acute care急诊期管护,Post-acute Care后急诊期管护,Lon-term care 长期管护,Intermittent rehabilitation(in-patient or day-clinic),Post-acute re

40、habilitation(in-patient),Community based rehabilitation(out-patient)基于康复的社交,Acute rehabilita-tion(in hospital),Prevention预防,Healthy living(integrated in daily living),Integrated phase model of rehabilitation care(agreed quality standards)协定质量标准,Intermittent intensive prevention(in-patient),Integrati

41、ve phase model of rehab care康复管护的综合阶段模型,间歇强化预防,间歇性康复,后急诊期康复,急诊期康复,Possible concrete projects 可能的具体项目,Design a rehabilitation system model in a defined region(project)在特定区域内设计一套康复系统模型 Create an academy for rehabilitation personnel(German-Chinese Rehabilitation Academy)为康复从业人员建立“德-中康复学院”Plan and reali

42、ze rehabilitation service for specific demands or target groups计划并实行针对特定需求及目标群体的康复服务 leaders and managers 面向领导及管理者 factories or industries 面向工厂或工业街 children or elderly people面向儿童或高龄人群 specific health conditions面向特定健康状况者 Plan and realize a comprehensive rehabilitation service in a defined area(town,n

43、eighborhood)在特定区域内计划并实行一套完整的康复服务（城镇、社区）Methods:use German model or integrate different international models and transform into a Chinese model方法：利用德国模式或综合不同国际模式，转化成中国特色模式,Challenges and opportunities:挑战与机遇 What are the challenges of planning and implementation projects?计划中和实施中的项目有什么样的挑战？What are the

44、 opportunities of collaboration?合作中的机遇是什么？,Challenges 挑战,Convince authorities 取得政府支持 Develop realistic plan 改善现实计划 Allocate money(find investors)非配资金（找到投资者）Set-up units(e.g.in hospital and/or as rehabilitation centres)建立康复单位（如建立康复医院或建立康复中心）Set-up programs(pathways and guidelines)建立项目（途径和方针）Train(or

45、recruit)workforce 培训（或引进）从业人员 Run service(leadership,quality management)运行服务（领导，质量管理）,Opportunities 机遇,Philosophy:develop Chinese model using German stndards理念：发展德标中用模式,Added value of Chinese and German expertise(and arguments)在中德经验求同存异中增加价值 Synergies with ISPRMs activities(WHO collaboration plan)利用

46、ISPRM活动的协同效应（WHO合作计划）Strong support from international organisations(and Chinese government)来自国际组织及中国官方的强力支持 Network of collaboration partners in Germany 德国合作伙伴网络 Access to German standards(and experience)(even if available in German language only),e.g.借鉴德方标准（及经验）（即使仅能使用德语交流）Rules for acute rehabili

47、tation急性期康复规则 Pathways for post acute rehabilitation后急性期通道 Vocational rehabilitation programs 专业的康复方案项目 and others 及其他 Available network(spirit of collaboration and mutual understanding)行之有效的网络（合作及理解互信的精神）,Networks 网络,Germany:德方 Hannover Medical School 汉诺威医学院 German Pension insurance(with rehab unit

48、s)德国养老保险（含康复单元部分）German Workers Accident insurance 德国工人意外保险 Chinabridge Germany China:中方 Nanjing University南京大学 Tonji University Wuhan 华中科技大学同济医学院 武汉 Chinabridge China International:国际 ISPRM(and other NGOs with relation to WHO)ISPRM（及其他WHO相关合作组织）,Outlook 展望,Rehabilitation should be implemented into

49、all phases of health care 康复应当在健康管护的全阶段进行 The implementation of high-quality rehabilitation programs can improve functioning and quality of life of patients after cardio-surgery高质量康复项目的实施可以改进心脏外科手术后的生活质量及功能 Rehabilitation programs also have the potential to reduce costs in health system 康复项目同样具有在健康系

50、统中节约资源的潜力 It makes sense to combine the rehabilitation strategy with preventive programs 康复策略同预防项目相结合具有积极意义 Concepts,standards and expertise exist to design good rehabilitation programs and service 概念、标准及专科决定了是否可以设计出好的康复项目 More scientific research on outcomes of rehabilitation is needed,in particula