哥本哈根市康復(fù)工作

哥本哈根市康復(fù)工作ResponsibilityforhealthinDenmark

丹麥醫(yī)療衛(wèi)生職責(zé)劃分TheState/Nationallevel國(guó)家層面MinistryofHealthandNationalBoardofHealth衛(wèi)生部和國(guó)家衛(wèi)生委員會(huì)Regulation,legislation,qualitystandardizations政策法規(guī)制定，質(zhì)量標(biāo)準(zhǔn)Regionallevel-TheCapitalRegion:大區(qū)級(jí)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(jí)別-哥本哈根市TheHealthandCareAdministration:衛(wèi)生保健部Healthpromotionanddiseasepreventionforallcitizens

全體民眾的健康促進(jìn)和疾病預(yù)防Rehabilitationprogramsafterdischargefromhospital (chronicdisease,muscularrehabilitation)出院后的康復(fù)項(xiàng)目（慢性疾病，肌肉康復(fù)）Elderlycareforcitizensage65andup–servicesandactivities年齡在65及以上民眾的養(yǎng)老服務(wù)–服務(wù)和活動(dòng)Rehabilitationwithouthospitalization無(wú)需住院的康復(fù)工作AfewfactsaboutCopenhagen哥本哈根部分?jǐn)?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(wàn)Lifeexpectancyforwomen:80years女性壽命:80歲Lifeexpectancyformen:74,7years男性壽命：74.7歲Strongpopulationgrowth:強(qiáng)勢(shì)人口增長(zhǎng)1000newcitizenseverymonth每月1000新市民In2025,therewillbe670,000

Copenhageners;anincreaseof33%

over20years.截止2025年，將達(dá)到670,000人，20年中33%的增長(zhǎng)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(huì)AuditDirectorateCopenhagen

哥本哈根審計(jì)總局CitizensAdviceService

公民咨詢服務(wù)TheFinance

Committee金融委員會(huì)TheCultureandLeisureCommittee

文化休閑委員會(huì)TheEmployment

andIntegration

Committee就業(yè)和一體化委員會(huì)TheTechnicaland

Environmental

Committee

技術(shù)和環(huán)境委員會(huì)TheChildrenand

YouthCommittee

兒童青少年委員會(huì)TheHealthand

CareCommittee

衛(wèi)生保健委員會(huì)TheSocial

Services

Committee

社會(huì)服務(wù)委員會(huì)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(fù)Rehabilitationafterfunctionaldeclineintheelderly老年人身體功能下降后的康復(fù)Rehabilitationofcitizenswithachronicdisease慢性病患者的康復(fù)Elderlycare:Includinghomecare,assistivedevices,residentialnursinghomes,rehabilitation,activityoffers,dentalcare,nursing,foodservice養(yǎng)老服務(wù)：包含家庭護(hù)理、輔助器械、居住性療養(yǎng)院、康復(fù)服務(wù)、活動(dòng)提議、牙科護(hù)理、護(hù)理服務(wù)、食品服務(wù)Healthpromotionanddiseasepreventionforallcitizens全體民眾的健康促進(jìn)和疾病預(yù)防

Healthcarechallengestothemunicipalities

市府的醫(yī)療衛(wèi)生挑戰(zhàn)Demography人口統(tǒng)計(jì)方面Moreelderlypeoplewithlongtermconditions.越來(lái)越多長(zhǎng)期病患的老年人In204025%ofthepopulationwillbemorethan65yearsofage(today19%)在2040年，25%的人口將超過(guò)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(dòng)力越來(lái)越少–納稅少，預(yù)算緊Expectations期望值方面Highexpectationstolifeasseniorcitizens老年人對(duì)生活的高期望Inequality不平等性SocialInequalityinthedistributionofhealth

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

2007TheLocalGovernmentReformandHealthLegislation2007年地方政府改革和衛(wèi)生立法Fundamentalreformationofthemunicipalities(from271to98)市級(jí)的巨大變革（從271個(gè)市到98個(gè)市）Everycitizenentitledtorehabilitationfreeofchargeintheirmunicipality,providedtheyhavearehabilitationplanfromthehospital只要市民有從醫(yī)院得到的康復(fù)計(jì)劃，他們就可享有免費(fèi)康復(fù)服務(wù)Rehabilitationbecametheresponsibilityofthemunicipalities康復(fù)服務(wù)成為市級(jí)政府的責(zé)任20082008年Municipalitiestakeoverresponsibilityforphysiotherapyfreeofchargeforcitizens(morediagnoses)市級(jí)政府接過(guò)為市民提供免費(fèi)理療的職責(zé)（更多的診斷）20152015年NewlegislationonrehabilitationinthemunicipalitiesandthehospitalsectorIntroducingabasicandadvancedlevelofrehabilitation.對(duì)市級(jí)和醫(yī)院中康復(fù)的新立法，帶來(lái)基本且提升的康復(fù)服務(wù)Newlegislationonrehabilitationinhomecare.對(duì)家庭護(hù)理康復(fù)的新立法Focusonthequalityofrehabilitation重視康復(fù)服務(wù)質(zhì)量

TheRegionallevel大區(qū)級(jí)別

DoctorsinthehospitalprescribesanRehabilitationplan醫(yī)院里的醫(yī)生指定康復(fù)計(jì)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(jí)別和市級(jí)別的衛(wèi)生任務(wù)Thereisaneedforco-ordinationand

cooperationbetweenprimaryand

secondarycare基礎(chǔ)醫(yī)護(hù)和二級(jí)醫(yī)護(hù)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(jí)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(fù)（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(fù)：在特定時(shí)期以目標(biāo)為導(dǎo)向通力合作的過(guò)程，這一過(guò)程涉及公民本人、他（她）的家屬以及專業(yè)人員。這一過(guò)程的目的是要確保病患，不論他的身體、精神和社會(huì)功能已經(jīng)嚴(yán)重縮水或有這方面的風(fēng)險(xiǎn)，都能夠?qū)崿F(xiàn)獨(dú)立和有意義的生活。康復(fù)需要考慮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(shí)層面的服務(wù)。Rehabilitationmindsetinelderlycare.

老年護(hù)理的康復(fù)觀念模式Settingupgoalsincollaborationwiththeoldperson與老年人建立合作目標(biāo)Aimingatindependencyandself-help以獨(dú)立和自立為目標(biāo)Involvementoftherelatives親屬參與Evidencebased循證Multiprofessionalismworkinginteams團(tuán)隊(duì)多元化專業(yè)合作Userinvolvementindecisions用戶參與決策Rehabilitationofbothphysical,mentalandsocialfunctions身體、精神和社會(huì)功能的康復(fù)Genericprocessinrehabilitation

康復(fù)的一般過(guò)程FunctionalDeclineoftheelderly老年人功能性衰弱

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

通過(guò)PSFS衡量效果Theimpactafterthreemonths(PSFS)三個(gè)月后的效果(PSFS)Settingupgoalsandplanningtheprocesswiththecitizen與公民制定目標(biāo)并且規(guī)劃過(guò)程Hospital醫(yī)院Neuro-rehabilitering神經(jīng)康復(fù)In-patientRehabilitering住院患者康復(fù)In-patientRehabiliteringCenterWelfaretechnology住院患者康復(fù)中心福利技術(shù)DementiaCenter老年癡呆癥中心Home家庭Nursinghome護(hù)理院Acutein-patientnursingcarecenterandPalliativeCenter急性住院患者護(hù)理中心和姑息治療中心GP全科醫(yī)生Shared-careunit共享監(jiān)護(hù)病房Rehabilitation康復(fù)Cohesiveandco-ordinatedpatientpathwayacrosssectors跨部門(mén)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(wèn)題Thequalityasperceivedbythecitizen市民角度的質(zhì)量問(wèn)題Theprofessionalquality專業(yè)質(zhì)量問(wèn)題Theorganizationalquality組織質(zhì)量問(wèn)題Makesuseof利用Usersurveys用戶調(diào)查Auditing審計(jì)Qualitycircleindevelopmentprojects開(kāi)發(fā)項(xiàng)目質(zhì)量Inspection檢驗(yàn)Nationalstrategiesfordigitalizationinthehealthsector.

國(guó)家健康部門(mén)數(shù)字化戰(zhàn)略

DigitalWelfare2013-2020:NationalplanforDigitalsupportanddigitalsolutionstowelfareservices.數(shù)字福利規(guī)劃2013-2020:國(guó)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(jìn)行康復(fù)治療？

Changes改變Empoweringthecitizen.Rehabilitationinfocus.授權(quán)于公民，專注于康復(fù)治療Makingtrainingavailabletothecitizen.Nomoretravellingpatients.向公民提供培訓(xùn)，減少患者出行Adherencetotherehabilitation:homeexercise,maintenanceofthetrainingeffort堅(jiān)持康復(fù)治療：家庭鍛煉、堅(jiān)持培訓(xùn)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(fù)治療方案數(shù)量將增加20%Digitalizationiscentralinthenationalstrategies數(shù)字化是國(guó)家戰(zhàn)略的核心Gainrealizationfrom2017自2017年起開(kāi)始實(shí)施Digitalsupporttorehabilitation.Stationarysensorsandpersonheldsensors

康復(fù)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(gè)人培訓(xùn)項(xiàng)目Deliveringvideo,auralinstructioninexercises提供視頻和聽(tīng)力指導(dǎo)訓(xùn)練Feedback,smileyandpercentachieved.得到熱情的反饋Accesstothetrainingdatahostedontheserverofthemanufacturer.訪問(wèn)制造商服務(wù)器上的培訓(xùn)數(shù)據(jù)PTcanaltertrainingattheadministrationsite理療師可以在管理網(wǎng)站更改訓(xùn)練項(xiàng)目Targetgroup目標(biāo)群體Frailelderlyinriskofadmission/readmission有住院和再住院風(fēng)險(xiǎn)的年老體弱者Elderlywithouttheenergytogototherehabilitationcentres.疲于前往康復(fù)中心的老年人Continuoustrainingbetweeninpatienttrainingandoutpatienttraining有持續(xù)住院和門(mén)診培訓(xùn)需求的人群Youngerpeopleactiveo