哥本哈根市康复工作课件

Rehabilitation in the City of Copenhagen 哥本哈根市康复工作,Merete Roen Christensen, Head of Quality and Rehabilitation Merete Roen Christensen, 哥本哈根市卫生保健部康复事务负责人（副司级） Lars Damkjaer, Special Consultant of Quality and Rehabilitation Lars Damkjaer， 哥本哈根市医疗保健部康复专家顾问 The Health and Care Administration, Municipality of Copenhagen Shanghai 15.-18 sept 2015,Responsibility for health in Denmark 丹麦医疗卫生职责划分,The State/National level 国家层面 Ministry of Health and National Board of Health卫生部和国家卫生委员会 Regulation, legislation, quality standardizations 政策法规制定，质量标准 Regional level - The Capital Region: 大区级别 首都大区 Hospital service somatic and psychiatric 医院服务 身体和精神 General practitioners, medical specialists etc. 全科医生，医疗专家等 Municipality level - City of Copenhagen, 市级别-哥本哈根市 The Health and Care Administration: 卫生保健部 Health promotion and disease prevention for all citizens 全体民众的健康促进和疾病预防 Rehabilitation programs after discharge from hospital (chronic disease, muscular rehabilitation) 出院后的康复项目 （慢性疾病，肌肉康复） Elderly care for citizens age 65 and up services and activities 年龄在65及以上民众的养老服务 服务和活动 Rehabilitation without hospitalization 无需住院的康复工作,A few facts about Copenhagen 哥本哈根部分数据,Municipality: 580.292 people (Denmark total: 5,7 mill.) Area: 89 km2 市：580.292人 (丹麦共5.700.000人）地域：89平方公里 Greater City area: 1,2 mill. Capital Region: 2 mill. People 城市大区：1.200.000, 哥本哈根大区: 2百万 Life expectancy for women: 80 years 女性寿命: 80岁 Life expectancy for men: 74,7 years 男性寿命：74.7岁 Strong population growth: 强势人口增长 1000 new citizens every month 每月1000新市民 In 2025, there will be 670,000 Copenhageners; an increase of 33% over 20 years.截止2025年，将达到 670,000人，20年中33%的增长 This is due to a high number of young incomers, a high ratio of births to deaths and immigration. 由于年轻人数量多，高出生死亡率以及移民 Therapists employed: 330 雇佣的治疗专家 330名,4,The Municipality of Copenhagen 哥本哈根市,Copenhagen City Council 哥本哈根市政委员会,Audit Directorate Copenhagen 哥本哈根审计总局,Citizens Advice Service 公民咨询服务,The Finance Committee 金融委员会,The Culture and Leisure Committee 文化休闲委员会,The Employment and Integration Committee 就业和一体化委员会,The Technical and Environmental Committee 技术和环境委员会,The Children and Youth Committee 儿童青少年委员会,The Health and Care Committee 卫生保健委员会,The Social Services Committee 社会服务委员会,Chairman 主席 Mayor Carl Christian Ebbesen,Chairman 主席 Lord Mayor Frank Jensen,Chairman主席 Mayor Anna Mee Allerslev,Chairman主席 Mayor Morten Kabell,Chairman主席 Mayor Jesper Christensen,Chairman主席 Mayor Ninna Thomsen,Chairman主席 Mayor Pia Allerslev,Administration,Administration,Administration 行政管理,Administration 行政管理,Administration 行政管理,Administration 行政管理,Administration 行政管理,Administration 行政管理,Administration 行政管理,The Health and Care Administration 卫生和保健部,Main tasks and services: 主要任务和服务 Rehabilitation after discharge from hospital 出院后康复 Rehabilitation after functional decline in the elderly 老年人身体功能下降后的康复 Rehabilitation of citizens with a chronic disease 慢性病患者的康复 Elderly care: Including home care, assistive devices, residential nursing homes, rehabilitation, activity offers, dental care, nursing, food service 养老服务：包含家庭护理、辅助器械、居住性疗养院、康复服务、活动提议、牙科护理、护理服务、食品服务 Health promotion and disease prevention for all citizens 全体民众的健康促进和疾病预防,The Regional level 大区级别,Doctors in the hospital prescribes an Rehabilitationplan 医院里的医生指定康复计划 healthcare agreements between municipalities and Region including GP 市府和大区间的卫生协议 包含全科医生 Health tasks on regional level and municipality level 大区级别和市级别的卫生任务 There is a need for co-ordination and cooperation between primary and secondary care 基础医护和二级医护间需要协调和合作,The Municipal Level 市级层面 The Health and Elderly Policies of Copenhagen 哥本哈根市卫生和养老政策,Health Policy 2015-25 卫生政策 2015-25,Copenhagen Elderly Policy 2015-2018 哥本哈根市养老政策 2015 2018,Rehabilitation (the Danish definition) 康复（丹麦的定义),The definition is as follows: 定义如下 Rehabilitation: A goal-oriented, cooperative process involving a citizen, his/her relatives, and professionals over a certain period of time. The aim of this process is to ensure that the person in question, who has, or is at risk of having, seriously diminished physical, mental and social functions, can achieve independence and a meaningful life. Rehabilitation takes account of the persons situation as a whole and the decisions he or she must make, and comprises coordinated, coherent, and knowledge based services. 康复：在特定时期以目标为导向通力合作的过程，这一过程涉及公民本人、他（她）的家属以及专业人员。这一过程的目的是要确保病患，不论他的身体、精神和社会功能已经严重缩水或有这方面的风险，都能够实现独立和有意义的生活。康复需要考虑到病患的整体情况以及他（她）所必须做出的决定，并且需要包含协调、一致和基于知识层面的服务。,Rehabilitation mindset in elderly care. 老年护理的康复观念模式,Setting up goals in collaboration with the old person 与老年人建立合作目标,Aiming at independency and self- help 以独立和自立为目标,Involvement of the relatives 亲属参与,Evidence based 循证,Multi professionalism working in teams 团队多元化专业合作,User involvement in decisions 用户参与决策,Rehabilitation of both physical, mental and social functions 身体、精神和社会功能的康复,Generic process in rehabilitation 康复的一般过程,28. marts 2019,13,In-patient Rehabilitering 住院患者康复,In-patient Rehabilitering Center Welfare technology 住院患者康复中心福利技术,Dementia Center 老年痴呆症中心,Home 家庭,Nursing home 护理院,Acute in-patient nursing care center and Palliative Center 急性住院患者护理中心和姑息治疗中心,GP 全科医生,Shared-care unit共享监护病房,Rehabilitation 康复 Cohesive and co-ordinated patient pathway across sectors 跨部门凝聚和协调病人的途径,Health Center 健康中心,Discharge coordi-nators 出院协调,Home 家庭,Quality management in the Health and Care administration of Copenhagen 哥本哈根市卫生保健管理中的质量管理,Quality organization 质量组织 Monitoring three dimensions of quality 监控三方面质量问题 The quality as perceived by the citizen 市民角度的质量问题 The professional quality 专业质量问题 The organizational quality 组织质量问题 Makes use of 利用 User surveys 用户调查 Auditing 审计 Quality circle in development projects 开发项目质量 Inspection 检验,National strategies for digitalization in the health sector. 国家健康部门数字化战略,Digital Welfare 2013-2020: National plan for Digital support and digital solutions to welfare services. 数字福利规划 2013-2020: 国家数字支持和解决方案福利规划 Time to change into less co-presence of citizen and health professional 转变至与健康专家更少相处,Digital support to rehabilitation Why? 为什么使用数字支持进行康复治疗？,Changes 改变 Empowering the citizen. Rehabilitation in focus. 授权于公民，专注于康复治疗 Making training available to the citizen. No more travelling patients. 向公民提供培训，减少患者出行 Adherence to the rehabilitation: home exercise, maintenance of the training effort 坚持康复治疗：家庭锻炼、坚持培训 When reducing the number of hospital beds 1/3 and 25% of the population more than 30km to nearest hospital(today 14%). We need new solutions 需要新的解决方案能将医院病床数量减少1/3，并将距离最近医院30公里的患者人群上升到25%左右（如今是14%） Challenges 挑战 Demography , more elderly 更多老年人口 20 % increase in rehabilitation plans from hospitals 医院康复治疗方案数量将增加20% Digitalization is central in the national strategies 数字化是国家战略的核心 Gain realization from 2017 自2017年起开始实施,Digital support to rehabilitation. Stationary sensors and person held sensors 康复数字支持：固定传感器和手持传感器,Virtuel Genoptrning DigiCorpus ICURA 3G telephone connection 3G 电话连接 Individualized training programs 个人培训项目 Delivering video, aural instruction in exercises 提供视频和听力指导训练 Feedback, smiley and percent achieved. 得到热情的反馈 Access to the training data hosted on the server of the manufacturer. 访问制造商服务器上的培训数据 PT can alter training at the administration site 理疗师可以在管理网站更改训练项目,Target group 目标群体 Frail elderly in risk of admission/readmission 有住院和再住院风险的年老体弱者 Elderly without the energy to go to the rehabilitation centres. 疲于前往康复中心的老年人 Continuous training between inpatient training and outpatient training 有持续住院和门诊培训需求的人群 Younger people active on the labour market, not having time to attend the training center 已经工作但疲于参加中心培训的年轻人 Business case 50% substitution 50%替代业务案例,Plans for Open Tele and Tel