社区-家庭康复一体化体系的建立.ppt

Linking Hospital with Community With a HARP ApproachWilfred Kwok郭伟权Physiotherapist, Ergonomist, Master TrainerMelbourne AUSTRALIA  Health Issues for Chronic Disease Patient长期病人之健康情 How to enhance patient health? 如何提升 How to facilitate patient take care of themselves?如何照护 How to assist patient more active more of the time? 如何增加活动时间 How to keep patient out of hospital?如何减少住医院时间 How to reduce hospital/medical cost?如何减灭医疗开支 Experience Sharing本讲标目 Health System Approach医疗制度操撕 Disease Self Management自我管理疾病 Exercise Habit Modification运动习惯 Effective Exercise Prescription运动处方 Contents: Hospital Risk Admission Program 医院风险计划 Chronic Disease Self Management 长期病自我管理 Clinical Tai Chi for Health and M.A.S.H. 自助互助诊冶太极 What is HARP ? H – Hospital 医院 A – Admission 入住使用 R – Risk 风险 P – Program 计划 HARP The Victorian Government in 2001-02. 2001 澳大利亚维省推动 The Department of Human Services committed $150 million to HARP over the four year period to June 2005. 2001-2005 费用是 1亿5百万元 HARP A model of care that involves hospitals and community agencies working in partnership to address the problem of increasing demand on hospital services 医疗及小区服务合力面对高使用量的增加 To improve health outcomes for people 提升病人生活质素及健康 HARP was created to address sustained increases in demand on the hospital system. 计划针对增加需要： an ageing population; 人口老化 new treatment options; 新法冶疗 reduced General Practitioner (GP) availability; 医生数量 residential care bed shortfalls; 医疗病床 workforce shortages; 工人短缺 reduction in the capacity of informal carers. 家居照护 HARP clients: 病人需要 improved health outcomes 健康质素 empowerment through education and self-management strategies 自我管理 individually tailored care 个别目标 chance to stay at home for longer 在家居住 The model of care for HARP CDM are based on the needs of Level 1 and Level 2 service users. 一般疾人的医疗使用分布 DHS funded 2 HARP programs:两科活动计划 Chronic Disease Management Program 长期病科 For people whose attendance is related specifically to COPD肺疾病 Heart failure/angina 心脏