哥本哈根市康復工作

1、Responsibility for health in Denmark丹麥醫(yī)療衛(wèi)生職責劃分丹麥醫(yī)療衛(wèi)生職責劃分The State/National level 國家層面國家層面 Ministry of Health and National Board of Health衛(wèi)生部和國家衛(wèi)生委員會Regulation, legislation, quality standardizations 政策法規(guī)制定，質量標準Regional level - The Capital Region: 大區(qū)級別大區(qū)級別 首都大區(qū)首都大區(qū)Hospital service somatic and psychiat

2、ric 醫(yī)院服務 身體和精神General practitioners, medical specialists etc. 全科醫(yī)生，醫(yī)療專家等Municipality level - City of Copenhagen, 市級別市級別-哥本哈根市哥本哈根市The Health and Care Administration: 衛(wèi)生保健部衛(wèi)生保健部Health promotion and disease prevention for all citizens全體民眾的健康促進和疾病預防Rehabilitation programs after discharge from hospital

3、(chronic disease, muscular rehabilitation) 出院后的康復項目 （慢性疾病，肌肉康復）Elderly care for citizens age 65 and up services and activities 年齡在65及以上民眾的養(yǎng)老服務 服務和活動Rehabilitation without hospitalization 無需住院的康復工作A few facts about Copenhagen 哥本哈根部分數據哥本哈根部分數據Municipality: 580.292 people (Denmark total: 5,7 mill.) Are

4、a: 89 km2市：580.292人 (丹麥共5.700.000人）地域：89平方公里Greater City area: 1,2 mill. Capital Region: 2 mill. People城市大區(qū)：1.200.000, 哥本哈根大區(qū): 2百萬Life expectancy for women: 80 years女性壽命: 80歲Life expectancy for men: 74,7 years男性壽命：74.7歲Strong population growth: 強勢人口增長強勢人口增長1000 new citizens every month 每月1000新市民In 2

5、025, there will be 670,000Copenhageners; an increase of 33%over 20 years.截止2025年，將達到 670,000人，20年中33%的增長 This is due to a high number of young incomers, a high ratio of births to deaths and immigration. 由于年輕人數量多，高出生死亡率以及移民Therapists employed: 330 雇傭的治療專家 330名4The Municipality of Copenhagen 哥本哈根市哥本哈根

6、市 Copenhagen City Council 哥本哈根市哥本哈根市政政委員會委員會Audit Directorate Copenhagen哥本哈根審計總局哥本哈根審計總局Citizens Advice Service公民咨詢服務公民咨詢服務The Finance Committee 金融委員會金融委員會The Culture and LeisureCommittee 文化休閑委員會文化休閑委員會The Employment and Integration Committee就業(yè)和一體化委員會就業(yè)和一體化委員會The Technical and Environmental Committe

7、e 技術和環(huán)境委員會技術和環(huán)境委員會The Children and Youth Committee兒童青少年委員會兒童青少年委員會The Health and Care Committee衛(wèi)生保健委員會衛(wèi)生保健委員會The Social ServicesCommittee社會服務委員會社會服務委員會Chairman 主席主席MayorCarl Christian Ebbesen Chairman 主席主席Lord MayorFrank Jensen Chairman主席主席Mayor Anna Mee AllerslevChairman主席主席MayorMorten Kabell Chair

8、man主席主席MayorJesper Christensen Chairman主席主席MayorNinna ThomsenChairman主席主席MayorPia Allerslev AdministrationAdministrationAdministration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 衛(wèi)生和保健部衛(wèi)生和保健部Main ta

9、sks and services: 主要任務和服務Rehabilitation after discharge from hospital 出院后康復Rehabilitation after functional decline in the elderly 老年人身體功能下降后的康復Rehabilitation of citizens with a chronic disease慢性病患者的康復Elderly care: Including home care, assistive devices, residential nursing homes, rehabilitation, act

10、ivity offers, dental care, nursing, food service 養(yǎng)老服務：包含家庭護理、輔助器械、居住性療養(yǎng)院、康復服務、活動提議、牙科護理、護理服務、食品服務Health promotion and disease prevention for all citizens全體民眾的健康促進和疾病預防 Healthcare challenges to the municipalities市府的醫(yī)療衛(wèi)生挑戰(zhàn)市府的醫(yī)療衛(wèi)生挑戰(zhàn)Demography 人口統(tǒng)計方面人口統(tǒng)計方面 More elderly people with long term conditions.

11、越來越多長期病患的老年人 In 2040 25% of the population will be more than 65 years of age (today 19%) 在2040年，25%的人口將超過65歲（目前為19%） Increase in chronic disease 慢性疾病增加Increased number of cancer survivors 癌癥病患幸存者增加Resources 資源方面資源方面 Fewer people in the workforce giving a smaller tax-base leading to a budget squeeze

12、勞動力越來越少 納稅少，預算緊 Expectations 期望值方面 High expectations to life as senior citizens老年人對生活的高期望Inequality 不平等性不平等性 Social Inequality in the distribution of health 衛(wèi)生資源分布方面的社會不平等性Shorter Hospitalization time 縮短的住院時間縮短的住院時間 from approx 9 days to 4.5 days ( going to 2.5 days)從大約9天到4.5天 （將降到2.5天）The National

13、level 國家層面國家層面2007 The Local Government Reform and Health Legislation 2007年地方政府改革和衛(wèi)生立法年地方政府改革和衛(wèi)生立法 Fundamental reformation of the municipalities (from 271 to 98) 市級的巨大變革（從271個市到98個市）Every citizen entitled to rehabilitation free of charge in their municipality, provided they have a rehabilitation pla

14、n from the hospital 只要市民有從醫(yī)院得到的康復計劃，他們就可享有免費康復服務 Rehabilitation became the responsibility of the municipalities 康復服務成為市級政府的責任2008 2008年年 Municipalities take over responsibility for physiotherapy free of charge for citizens (more diagnoses) 市級政府接過為市民提供免費理療的職責（更多的診斷）2015 2015年年New legislation on rehab

15、ilitation in the municipalities and the hospital sector Introducing a basic and advanced level of rehabilitation. 對市級和醫(yī)院中康復的新立法，帶來基本且提升的康復服務New legislation on rehabilitation in home care. 對家庭護理康復的新立法Focus on the quality of rehabilitation 重視康復服務質量The Regional level 大區(qū)級別大區(qū)級別Doctors in the hospital pre

16、scribes an Rehabilitationplan 醫(yī)院里的醫(yī)生指定康復計劃醫(yī)院里的醫(yī)生指定康復計劃healthcare agreements between municipalities and Region including GP市府和大區(qū)間的衛(wèi)生協(xié)議 包含全科醫(yī)生Health tasks on regional level and municipality level大區(qū)級別和市級別的衛(wèi)生任務There is a need for co-ordination and cooperation between primary and secondary care基礎醫(yī)護和二級醫(yī)護間

17、需要協(xié)調和合作GP全科醫(yī)生Municipality市政府Hospital 醫(yī)院The Municipal Level 市級層面市級層面The Health and Elderly Policies of Copenhagen哥本哈根市衛(wèi)生和養(yǎng)老政策Health Policy 2015-25衛(wèi)生政策 2015-25 Copenhagen Elderly Policy 2015-2018哥本哈根市養(yǎng)老政策 2015 2018 Rehabilitation (the Danish definition)康復（丹麥的定義康復（丹麥的定義) The definition is as follows: 定

18、義如下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 functi

19、ons, 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. 康復：在特定時期以目標為導向通力合作的過程，這一過程涉及公民本人、他（她）的家屬以及專業(yè)人員。這一過程的目的是要確保病患，不論他的身體、精神和社會功能已

20、經嚴重縮水或有這方面的風險，都能夠實現獨立和有意義的生活?？祻托枰紤]到病患的整體情況以及他（她）所必須做出的決定，并且需要包含協(xié)調、一致和基于知識層面的服務。Rehabilitation mindset in elderly care.老年護理的康復觀念模式老年護理的康復觀念模式Setting up goals in collaboration with the old person 與老年人建立合作目標Aiming at independency and self- help以獨立和自立為目標Involvement of the relatives親屬參與Evidence based循證M

21、ulti professionalism working in teams團隊多元化專業(yè)合作User involvement in decisions用戶參與決策Rehabilitation of both physical, mental and social functions身體、精神和社會功能的康復Generic process in rehabilitation康復的一般過程康復的一般過程Functional Decline of the elderly老年人功能性衰弱 - Potential 潛能- Motivation 激勵- Involving relatives if rel

22、evant 包括相關的親屬Ongoing follow-up with the citizen. Measuring effect using PSFS對公民持續(xù)跟蹤 通過PSFS衡量效果The impact after three months (PSFS)三個月后的效果(PSFS)Setting up goals and planning the process with the citizen與公民制定目標并且規(guī)劃過程2/12/202213Hospital 醫(yī)院Neuro-rehabilitering神經康復In-patientRehabilitering住院患者康復In-patient

23、Rehabilitering Center Welfare technology住院患者康復中心福利技術Dementia Center老年癡呆癥中心Home家庭家庭Nursing home 護理院Acute in-patient nursing care center and Palliative Center急性住院患者護理中心和姑息治療中心GP全科醫(yī)生Shared-care unit共享監(jiān)護共享監(jiān)護病房病房Rehabilitation 康復康復Cohesive and co-ordinated patient pathway across sectors跨部門凝聚和協(xié)調病人的途徑跨部門凝聚

24、和協(xié)調病人的途徑Health Center健康中心Discharge coordi-nators 出院協(xié)調出院協(xié)調Home家庭家庭Quality management in the Health and Care administration of Copenhagen哥本哈根市衛(wèi)生保健管理中的質量管理哥本哈根市衛(wèi)生保健管理中的質量管理Quality organization 質量組織Monitoring three dimensions of quality監(jiān)控三方面質量問題The quality as perceived by the citizen 市民角度的質量問題The profes

25、sional quality 專業(yè)質量問題The organizational quality 組織質量問題Makes use of 利用User surveys 用戶調查Auditing 審計Quality circle in development projects 開發(fā)項目質量Inspection 檢驗 National strategies for digitalization in the health sector.國家健康部門數字化戰(zhàn)略國家健康部門數字化戰(zhàn)略Digital Welfare 2013-2020: National plan for Digital support a

26、nd digital solutions to welfare services.數字福利規(guī)劃 2013-2020: 國家數字支持和解決方案福利規(guī)劃Time to change into less co-presence of citizen and health professional轉變至與健康專家更少相處Digital support to rehabilitation Why?為什么使用數字支持進行康復治療？為什么使用數字支持進行康復治療？Changes 改變改變Empowering the citizen. Rehabilitation in focus.授權于公民，專注于康復治療

27、Making training available to the citizen. No more travelling patients.向公民提供培訓，減少患者出行Adherence to the rehabilitation: home exercise, maintenance of the training effort堅持康復治療：家庭鍛煉、堅持培訓When reducing the number of hospital beds 1/3 and 25% of the population more than 30km to nearest hospital(today 14%).

28、 We need new solutions需要新的解決方案能將醫(yī)院病床數量減少1/3，并將距離最近醫(yī)院30公里的患者人群上升到25%左右（如今是14%）Challenges 挑戰(zhàn)挑戰(zhàn)Demography , more elderly 更多老年人口20 % increase in rehabilitation plans from hospitals 醫(yī)院康復治療方案數量將增加20% Digitalization is central in the national strategies數字化是國家戰(zhàn)略的核心Gain realization from 2017自2017年起開始實施Digita

29、l support to rehabilitation. Stationary sensors and person held sensors康復數字支持：固定傳感器和手持傳感器康復數字支持：固定傳感器和手持傳感器Virtuel GenoptrningDigiCorpus ICURA3G telephone connection3G 電話連接Individualized training programs個人培訓項目Delivering video, aural instruction in exercises提供視頻和聽力指導訓練Feedback, smiley and percent ac

30、hieved.得到熱情的反饋Access to the training data hosted on the server of the manufacturer.訪問制造商服務器上的培訓數據PT can alter training at the administration site理療師可以在管理網站更改訓練項目Target group 目標群體目標群體 Frail elderly in risk of admission/readmission有住院和再住院風險的年老體弱者 Elderly without the energy to go to the rehabilitation centres.疲于前往康復中心的老年人Continuous training between inpatient training and outpatient training有持續(xù)住院和門診培訓需求的人群Younger people active on the labour market, not having time to attend the training center已經工作但疲于參加中心培訓的年輕人Business case 50% substitution50%替代業(yè)務案例Plans