哥本哈根市康復工作

哥本哈根市康復工作ResponsibilityforhealthinDenmark

丹麥醫(yī)療衛(wèi)生職責劃分TheState/Nationallevel國家層面MinistryofHealthandNationalBoardofHealth衛(wèi)生部和國家衛(wèi)生委員會Regulation,legislation,qualitystandardizations政策法規(guī)制定，質(zhì)量標準Regionallevel-TheCapitalRegion:大區(qū)級別–首都大區(qū)Hospitalservice–somaticandpsychiatric醫(yī)院服務(wù)–身體和精神Generalpractitioners,medicalspecialistsetc.全科醫(yī)生，醫(yī)療專家等Municipalitylevel-CityofCopenhagen,市級別-哥本哈根市TheHealthandCareAdministration:衛(wèi)生保健部Healthpromotionanddiseasepreventionforallcitizens

全體民眾的健康促進和疾病預防Rehabilitationprogramsafterdischargefromhospital (chronicdisease,muscularrehabilitation)出院后的康復項目（慢性疾病，肌肉康復）Elderlycareforcitizensage65andup–servicesandactivities年齡在65及以上民眾的養(yǎng)老服務(wù)–服務(wù)和活動Rehabilitationwithouthospitalization無需住院的康復工作AfewfactsaboutCopenhagen哥本哈根部分數(shù)據(jù)Municipality:580.292people(Denmarktotal:5,7mill.)Area:89km2市：580.292人(丹麥共5.700.000人）地域：89平方公里GreaterCityarea:1,2mill.CapitalRegion:2mill.People城市大區(qū)：1.200.000,哥本哈根大區(qū):2百萬Lifeexpectancyforwomen:80years女性壽命:80歲Lifeexpectancyformen:74,7years男性壽命：74.7歲Strongpopulationgrowth:強勢人口增長1000newcitizenseverymonth每月1000新市民In2025,therewillbe670,000

Copenhageners;anincreaseof33%

over20years.截止2025年，將達到670,000人，20年中33%的增長Thisisduetoahighnumberofyoung

incomers,ahighratioofbirthstodeaths

andimmigration.由于年輕人數(shù)量多，高出生死亡率以及移民Therapistsemployed:330雇傭的治療專家330名TheMunicipalityofCopenhagen哥本哈根市CopenhagenCityCouncil哥本哈根市政委員會AuditDirectorateCopenhagen

哥本哈根審計總局CitizensAdviceService

公民咨詢服務(wù)TheFinance

Committee金融委員會TheCultureandLeisureCommittee

文化休閑委員會TheEmployment

andIntegration

Committee就業(yè)和一體化委員會TheTechnicaland

Environmental

Committee

技術(shù)和環(huán)境委員會TheChildrenand

YouthCommittee

兒童青少年委員會TheHealthand

CareCommittee

衛(wèi)生保健委員會TheSocial

Services

Committee

社會服務(wù)委員會Chairman主席MayorCarlChristianEbbesenChairman主席LordMayorFrankJensenChairman主席MayorAnnaMee

AllerslevChairman主席MayorMortenKabellChairman主席

MayorJesperChristensenChairman主席MayorNinnaThomsenChairman主席MayorPiaAllerslevAdministrationAdministrationAdministration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4

TheHealthandCareAdministration衛(wèi)生和保健部

Maintasksandservices:主要任務(wù)和服務(wù)Rehabilitationafterdischargefromhospital出院后康復Rehabilitationafterfunctionaldeclineintheelderly老年人身體功能下降后的康復Rehabilitationofcitizenswithachronicdisease慢性病患者的康復Elderlycare:Includinghomecare,assistivedevices,residentialnursinghomes,rehabilitation,activityoffers,dentalcare,nursing,foodservice養(yǎng)老服務(wù)：包含家庭護理、輔助器械、居住性療養(yǎng)院、康復服務(wù)、活動提議、牙科護理、護理服務(wù)、食品服務(wù)Healthpromotionanddiseasepreventionforallcitizens全體民眾的健康促進和疾病預防

Healthcarechallengestothemunicipalities

市府的醫(yī)療衛(wèi)生挑戰(zhàn)Demography人口統(tǒng)計方面Moreelderlypeoplewithlongtermconditions.越來越多長期病患的老年人In204025%ofthepopulationwillbemorethan65yearsofage(today19%)在2040年，25%的人口將超過65歲（目前為19%）Increaseinchronicdisease慢性疾病增加Increasednumberofcancersurvivors癌癥病患幸存者增加Resources資源方面Fewerpeopleintheworkforce–givingasmallertax-baseleadingtoabudgetsqueeze勞動力越來越少–納稅少，預算緊Expectations期望值方面Highexpectationstolifeasseniorcitizens老年人對生活的高期望Inequality不平等性SocialInequalityinthedistributionofhealth

衛(wèi)生資源分布方面的社會不平等性ShorterHospitalizationtime縮短的住院時間fromapprox9daysto4.5days(goingto2.5days)從大約9天到4.5天（將降到2.5天）TheNationallevel國家層面

2007TheLocalGovernmentReformandHealthLegislation2007年地方政府改革和衛(wèi)生立法Fundamentalreformationofthemunicipalities(from271to98)市級的巨大變革（從271個市到98個市）Everycitizenentitledtorehabilitationfreeofchargeintheirmunicipality,providedtheyhavearehabilitationplanfromthehospital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(wù)Rehabilitationbecametheresponsibilityofthemunicipalities康復服務(wù)成為市級政府的責任20082008年Municipalitiestakeoverresponsibilityforphysiotherapyfreeofchargeforcitizens(morediagnoses)市級政府接過為市民提供免費理療的職責（更多的診斷）20152015年NewlegislationonrehabilitationinthemunicipalitiesandthehospitalsectorIntroducingabasicandadvancedlevelofrehabilitation.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(wù)Newlegislationonrehabilitationinhomecare.對家庭護理康復的新立法Focusonthequalityofrehabilitation重視康復服務(wù)質(zhì)量

TheRegionallevel大區(qū)級別

DoctorsinthehospitalprescribesanRehabilitationplan醫(yī)院里的醫(yī)生指定康復計劃healthcareagreementsbetweenmunicipalities

andRegion–includingGP市府和大區(qū)間的衛(wèi)生協(xié)議–包含全科醫(yī)生Healthtasksonregionallevelandmunicipalitylevel

大區(qū)級別和市級別的衛(wèi)生任務(wù)Thereisaneedforco-ordinationand

cooperationbetweenprimaryand

secondarycare基礎(chǔ)醫(yī)護和二級醫(yī)護間需要協(xié)調(diào)和合作

GP全科醫(yī)生Municipality市政府Hospital醫(yī)院TheMunicipalLevel市級層面

TheHealthandElderlyPoliciesofCopenhagen

哥本哈根市衛(wèi)生和養(yǎng)老政策HealthPolicy2015-25衛(wèi)生政策2015-25CopenhagenElderlyPolicy2015-2018哥本哈根市養(yǎng)老政策2015–2018Rehabilitation(theDanishdefinition)

康復（丹麥的定義)Thedefinitionisasfollows:定義如下Rehabilitation:Agoal-oriented,cooperativeprocessinvolvingacitizen,his/herrelatives,andprofessionalsoveracertainperiodoftime.Theaimofthisprocessistoensurethatthepersoninquestion,whohas,orisatriskofhaving,seriouslydiminishedphysical,mentalandsocialfunctions,canachieveindependenceandameaningfullife.Rehabilitationtakesaccountoftheperson'ssituationasawholeandthedecisionsheorshemustmake,andcomprisescoordinated,coherent,andknowledgebasedservices.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、精神和社會功能已經(jīng)嚴重縮水或有這方面的風險，都能夠?qū)崿F(xiàn)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(diào)、一致和基于知識層面的服務(wù)。Rehabilitationmindsetinelderlycare.

老年護理的康復觀念模式Settingupgoalsincollaborationwiththeoldperson與老年人建立合作目標Aimingatindependencyandself-help以獨立和自立為目標Involvementoftherelatives親屬參與Evidencebased循證Multiprofessionalismworkinginteams團隊多元化專業(yè)合作Userinvolvementindecisions用戶參與決策Rehabilitationofbothphysical,mentalandsocialfunctions身體、精神和社會功能的康復Genericprocessinrehabilitation

康復的一般過程FunctionalDeclineoftheelderly老年人功能性衰弱

Potential潛能Motivation激勵I(lǐng)nvolvingrelativesifrelevant包括相關(guān)的親屬Ongoingfollow-upwiththecitizen.MeasuringeffectusingPSFS對公民持續(xù)跟蹤

通過PSFS衡量效果Theimpactafterthreemonths(PSFS)三個月后的效果(PSFS)Settingupgoalsandplanningtheprocesswiththecitizen與公民制定目標并且規(guī)劃過程Hospital醫(yī)院Neuro-rehabilitering神經(jīng)康復In-patientRehabilitering住院患者康復In-patientRehabiliteringCenterWelfaretechnology住院患者康復中心福利技術(shù)DementiaCenter老年癡呆癥中心Home家庭Nursinghome護理院Acutein-patientnursingcarecenterandPalliativeCenter急性住院患者護理中心和姑息治療中心GP全科醫(yī)生Shared-careunit共享監(jiān)護病房Rehabilitation康復Cohesiveandco-ordinatedpatientpathwayacrosssectors跨部門凝聚和協(xié)調(diào)病人的途徑HealthCenter健康中心Dischargecoordi-nators出院協(xié)調(diào)Home家庭09-04-202313QualitymanagementintheHealthandCareadministrationofCopenhagen

哥本哈根市衛(wèi)生保健管理中的質(zhì)量管理

Qualityorganization質(zhì)量組織Monitoringthreedimensionsofquality監(jiān)控三方面質(zhì)量問題Thequalityasperceivedbythecitizen市民角度的質(zhì)量問題Theprofessionalquality專業(yè)質(zhì)量問題Theorganizationalquality組織質(zhì)量問題Makesuseof利用Usersurveys用戶調(diào)查Auditing審計Qualitycircleindevelopmentprojects開發(fā)項目質(zhì)量Inspection檢驗Nationalstrategiesfordigitalizationinthehealthsector.

國家健康部門數(shù)字化戰(zhàn)略

DigitalWelfare2013-2020:NationalplanforDigitalsupportanddigitalsolutionstowelfareservices.數(shù)字福利規(guī)劃2013-2020:國家數(shù)字支持和解決方案福利規(guī)劃Timetochangeintolessco-presenceofcitizenandhealthprofessional轉(zhuǎn)變至與健康專家更少相處DigitalsupporttorehabilitationWhy

為什么使用數(shù)字支持進行康復治療？

Changes改變Empoweringthecitizen.Rehabilitationinfocus.授權(quán)于公民，專注于康復治療Makingtrainingavailabletothecitizen.Nomoretravellingpatients.向公民提供培訓，減少患者出行Adherencetotherehabilitation:homeexercise,maintenanceofthetrainingeffort堅持康復治療：家庭鍛煉、堅持培訓Whenreducingthenumberofhospitalbeds1/3and25%ofthepopulationmorethan30kmtonearesthospital(today14%).Weneednewsolutions需要新的解決方案能將醫(yī)院病床數(shù)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)Demography,moreelderly更多老年人口20%increaseinrehabilitationplansfromhospitals醫(yī)院康復治療方案數(shù)量將增加20%Digitalizationiscentralinthenationalstrategies數(shù)字化是國家戰(zhàn)略的核心Gainrealizationfrom2017自2017年起開始實施Digitalsupporttorehabilitation.Stationarysensorsandpersonheldsensors

康復數(shù)字支持：固定傳感器和手持傳感器

VirtuelGenoptr?ning?DigiCorpus?ICURA?3Gtelephoneconnection3G電話連接Individualizedtrainingprograms個人培訓項目Deliveringvideo,auralinstructioninexercises提供視頻和聽力指導訓練Feedback,smileyandpercentachieved.得到熱情的反饋Accesstothetrainingdatahostedontheserverofthemanufacturer.訪問制造商服務(wù)器上的培訓數(shù)據(jù)PTcanaltertrainingattheadministrationsite理療師可以在管理網(wǎng)站更改訓練項目Targetgroup目標群體Frailelderlyinriskofadmission/readmission有住院和再住院風險的年老體弱者Elderlywithouttheenergytogototherehabilitationcentres.疲于前往康復中心的老年人Continuoustrainingbetweeninpatienttrainingandoutpatienttraining有持續(xù)住院和門診培訓需求的人群Youngerpeopleactiveo