(中德康復技術培訓課件)2506 Gutenbrunner 中徳康復合作領域

Systematicapproachtoimplementrehabilitationinhealthsystems–collaborationbetweenChinaandGermany完成健康體系中的康復醫(yī)學的系統(tǒng)化處理方法-中德合作

ChristophGutenbrunnerChristophGutenbrunner,MD,PhD,ProfessorDepartmentforRehabilitationMedicineCoordinationCentreforRehabilitationResearchHanoverMedicalSchoolD-30625Hannovergutenbrunner.christoph@mh-hannover.deSystematicapproachtoimplemeOverview內容概要?Arguments:whyshouldweworkontheimplementationof rehabilitationservices?論證：為什么我們應當致力于康復服務的實行？?Conceptualapproach:howtoanalyse,plananimplement rehabilitationservices概念性的探討：如何分析，計劃康復服務的實行?Challengesandopportunities: 挑戰(zhàn)與機遇

?Whatarethechallengesofplanningandimplementation projects?計劃和和實行方案會有著怎樣的挑戰(zhàn)?Whataretheopportunitiesofcollaboration?相互合作會帶來什么樣的機遇Overview內容概要?Arguments:whyArguments:whyshouldweworkontheimplementationof rehabilitationservices?論證：為什么我們應當致力于康復服務的實行？Arguments:whyshouldwework?TheInternationalClassificationofFunctioning,DisabilityandHealth (2001)國際健康功能與身心障礙分類系統(tǒng)?UN-ConventionfortheRightsofPeoplewithDisabilities(2006)聯(lián)合國殘疾人權利公約?WorldReportonDisability(2011)

世界殘疾報告?The“InternationalPerspectivesofSpinalCordInjury”Report(2013)脊髓損傷國際展望報告?ResolutionWHA66.9?Disability“(2013)世界衛(wèi)生大會66.9號殘疾決議?TheWHOGlobalDisabilityActionPlan?BetterHealthforallpeople withdisabilities2014-2021“(2014)世衛(wèi)組織2014–2021年全球殘疾問題行動計劃：增進所有殘疾人的健康Theinternational“normative”approach國際”標準化“?TheInternationalClassificaTheUN-CRPD

(2006)聯(lián)合國殘疾人權力公約?Article26:HabilitationandRehabilitation ?StatesPartiesshalltakeeffectiveandappropriate measures,includingthroughpeersupport,toenable personswithdisabilitiestoattainandmaintain maximumindependence,fullphysical,mental,social andvocationalability,andfullinclusionand participationinallaspectsoflife.Tothatend,States Partiesshallorganize,strengthenandextend comprehensivehabilitationandrehabilitation servicesandprogrammes,particularlyintheareas ofhealth,employment,educationandsocial services,(…)第26條：適應訓練和康復締約國應當采取有效和適當?shù)拇胧?，包括通過殘疾人相互支持，使殘疾人能夠實現(xiàn)和保持最大程度的自立，充分發(fā)揮和維持體能、智慧、社會和職業(yè)能力，充分融入和參與生活的各個方面。為此目的，締約國應當組織、加強和推廣綜合性適應訓練和康復服務和方案，尤其是在醫(yī)療衛(wèi)生、就業(yè)、教育和社會服務方面TheUN-CRPD(2006)聯(lián)合國殘疾人權力公約?ActionPlan:objectives行動計劃：三大目標(1)

toremovebarriersandimproveaccesstohealthservicesand programmes1)清除障礙并提高衛(wèi)生服務和規(guī)劃的可及性(2)

tostrengthenandextendrehabilitation,habilitation,assistive technology,assistanceandsupportservices,andcommunity- basedrehabilitation(2)加強和推廣康復、適應訓練、輔助技術、援助和支持性服務以及以社區(qū)為基礎的康復(3)tostrengthencollectionofrelevantandinternationallycomparabledataondisabilityandsupportresearchondisabilityand

relatedservices

(3)加強收集殘疾方面國際上可對比的相關數(shù)據(jù)，并支持關于殘疾和相關服務的研究ActionPlan:objectives行動計劃：三大TheWHOGlobalDisabilityActionPlan

(2014)世衛(wèi)組織全球殘疾問題行動計劃?Objective2:tostrengthenandextendrehabilitation,habilitation, assistivetechnology,assistanceandsupportservices,and community-basedrehabilitation目標2:加強和推廣康復、適應訓練、輔助技術、援助和支持性服務以及以社區(qū)為基礎的康復 ?Action2.4:Expandandstrengthenrehabilitationand habilitationservicesensuringintegration,acrossthe continuumofcare,intoprimary(including community),secondaryandtertiarylevelsofthe healthcaresystem,andequitableaccess,including timelyearlyinterventionservicesforchildrenwith disabilities2．4擴大并加強康復和適應訓練服務，確保與持續(xù)照護一起納人初級(包括社區(qū))、二級和三級衛(wèi)生保健系統(tǒng)，并確保公平獲取服務。包括為殘疾兒童及時提供早期干預服務TheWHOGlobalDisabilityActiTheWHOGlobalDisabilityActionPlan

(2014)?ProposedinputsforMemberStates: ?Reviewexistingrehabilitationandhabilitationprogrammes andservicesandmakenecessarychangesto improvecoverage,effectivenessandefficiency建議會員國開展的工作：審查現(xiàn)有康復規(guī)劃和服務并作出必要的改變以提高覆蓋率、有效性和效率?ProposedinputsfortheSecretariat: ?Supportcountriesinintegratingrehabilitationandhabilitation servicesintothehealthsystem(…) ?Developrelevanttoolsandtrainingpackagestodevelop andstrengthenhabilitationandrehabilitationservices秘書處的工作：支持國家把康復和適應訓練服務納入衛(wèi)生系統(tǒng).制定相關的工具和培訓一攬子計劃，以便發(fā)展和加強適應訓練及康復服務?Proposedinputsforinternationalandnationalpartners: ?Workwithhealthministriestoexpandandstrengthenthe provisionofrehabilitationandhabilitationservices建議國際和國家伙伴開展的工作：與衛(wèi)生部一起開展工作，推廣和加強提供康復服務TheWHOGlobalDisabilityActiHealthaccountsvs.strategiesNoDimensionsofICHA-HCHealthCareStrategies(Stuckietal.)衛(wèi)生保健策略1HC.1:Servicesofcurativecare根治性治療服務Curativecare(curativestrategy)根治治療(根治性策略）2HC.2:Servicesofrehabilitativecare康復治療服務Rehebilitativecare(rehabilitativestrategy)康復治療（康復性策略）3HC.3:Servicesoflong-termnursingcare長期護理服務Maintenancecare(supportivestrategy)保養(yǎng)治療（支持性策略）4HC.4:Ancillaryservicestohealthcare衛(wèi)生保健的附屬服務5HC.5:Medicalgoodsdispensedtoout-patients門診病人的醫(yī)療用品發(fā)放6HC.6:Preventionandpublichealthservices預防與公共衛(wèi)生服務Prevention(preventivestrategy)預防（預防性策略）7HC.7:Healthadministrationandhealthinsurance衛(wèi)生行政與健康保險Healthaccountsvs.strategiesIn-patientordayclinicrehabilitationforpatientswithchronicconditionsLevelstodescriberehabilitation康復的各描述水平Macrolevel宏觀水平Mesolevel中間水平Microlevel微觀水平Healthstrategy,policy健康策略及政策Serviceprovision,concepts服務分配及慨念Healthcondition&functionallevel(B)Healthcondition&functionallevel(A)健康條件及功能水平（A)….In-patientordayclinicrehabTimeIntensity強度Acutecare急性治療Post-acutecare急性期治療Lon-termcare長期治療Intermittentrehabilitation(in-patientorday-clinic)間斷性康復（門診或日間診所）Post-acurterehabilitation(in-patient)急性期后康復（住院病人）Communitybasedrehabilitation(out-patient)以社區(qū)為基礎的康復（門診病人）Acuterehabilita-tion(inhospital)急性康復（院內）Integrativephasemodelofrehabcare康復治療的整合分期模式GutenbrunnerC,MeyerT,StuckiG::AmJPhysMedRehabil2011;90:521-525TimeIntensity強度Acutecare急性治療PLevel4:Multi-professionalrehabilitationservices水平4多專業(yè)性康復服務Level1:families,peers,etc.水平1：家庭，病友等等Level3:PRM,specializedPT,OTetc.水平3：康健醫(yī)學，專業(yè)理療師，職業(yè)治療師等等Level2:primarycarephysicians,PT,OT,etc.水平2：初級護理醫(yī)生，理療師，職業(yè)治療師等等Coordinatedreferralsystems(PRMasadvisorandcoordinator)←PRMdeliveredservicesPRMastrainer?Level5:highlyspecializedrehabilitationservices(SCI,TBI)水平5高專業(yè)化的康復服務（脊髓創(chuàng)傷，腦創(chuàng)傷Levelsofspecialization康康復專業(yè)水平Level4:Multi-professionalCommunityBasedRehabilitation基于社區(qū)的康復GutenbrunnerC(2014):submittedCommunityBasedRehabilitationThehealthsystemsapproach衛(wèi)生系統(tǒng)探討?Rehabilitationcanbeseenasahealthstrategyitalsoisdescribed as“asetofmeasures” 康復可被視為健康戰(zhàn)略也可描述成”一攬子計劃”?Rehabilitationshouldbeintegratedinacute,post-acuteand long-termcare康復應被整合于急性期,急性期后及長期性治療中?Rehabilitationshouldbeintegratedinprimary,secondaryandtertiary levelsofhealthcareservices康復應被整合于醫(yī)療服務的一級至三級水平中?Multi-professionalrehabilitationservicesneedhighstandardof serviceprovisionincludingresourcessuchasfacilities, technicalequipmentandhumanresources多專業(yè)性康復服務需要高標準的服務供給,包括設施,技術設備及人力資源Thehealthsystemsapproach衛(wèi)生系Theindividualapproach(examples)病人個人探討(舉例)?Patientswithlongtermmechanicalventilationwilldevelop contractures,looseventilationcapacity,developmuscle atrophy,loosecirculatorycapacity,areinriskofpneumonia andthrombosisandothers機械通氣患者常會發(fā)展有氣管痙攣,肺活量降低,肌肉萎縮,循環(huán)血量降低等并發(fā)癥,處于發(fā)生肺炎,血栓及其他的危險下.?Patientsafterstrokewilllooseopportunitytoinduceneuroplasticityif rehabilitationdoesnotstartimmediatelyafterincident腦卒中病人若在事件后未立即進行康復治療,神經(jīng)可塑性引導的可能性講會降低?Patientswithmusculo-skeletalpainsyndromesareatriskdo developchronicgeneralisedpainsyndromesifprimary sourceofpainisnottreatedsufficiently肌肉骨骼疼痛癥患者如疼痛的首因未被有效治療,將可能發(fā)展成為慢性廣泛性疼痛綜合征.?Patientswithchronichealthconditionsareatrisktobeunfitforwork ifrehabilitationislacking慢性疾病患者常可被危及無法適應于工作,如果康復醫(yī)療缺失的話?Lackofrehabilitationisahealthrisk,threattodevelopdisability缺失康復是一個健康風險,甚至可威脅發(fā)展至殘疾Theindividualapproach(exampEconomic&developmentapproach

(arguments)經(jīng)濟與發(fā)展探討(論證)?Lackofrehabilitationincreasecostsofhealthcareandsocial compensation,缺少康復會導致健康醫(yī)療費用的增長及社會補償e.g.

例如 ?lengthofstayinICU‘saninhospitalwillbelongerICU時間將會增加 ?outcomesofinterventions(e.g.surgery)willbepoorer ?干預手段(如外科手術)的結果變差theprevalenceofdisabilitywillbehigher 致殘發(fā)生率增加 ?Contributionofindividualstosociety(andsocialproductivity) willbelower個人對社會(和社會生產(chǎn)力)的貢獻減少?Lackofrehabilitationisaneconomicanddevelopmentalrisk,e.g. ?disabilitywithoutrehabilitationisaburdenforhealthsystems ?Lackofemployees(esp.ofhigheducation)harmsdevelopmentalprocesses缺少康復是一個經(jīng)濟和發(fā)展危險因素，例如無康復醫(yī)療的殘疾會成為衛(wèi)生系統(tǒng)的負擔。缺少被雇傭者（尤其受過高等教育）會損害發(fā)展過程?Theprovisionofrehabilitationservicesmayalsobeabusiness康復服務的分配也可成為Economic&developmentapproacConceptualapproach:howtoanalyse,plananimplementrehabilitationservices

概念方法：如何分析，計劃開展康復服務Conceptualapproach:howtoanStepwiseapproach(1)階梯式方法?Step1:Agreementonbasicprinciples(e.g.UN-CRPD,WRD,WHA Resolution66.9,Disabilityactionplan)第一階段達成基本共識?Step2:Analysisoftheburdenandmajorcausesofdisability:

第二階段殘障的主要原因及難點分析

?Trafficaccidentsandothertrauma(incl.spinalcordinjury, traumaticbraininjury,multipletrauma)交通事故及其他外傷

?Cardiovascularandmetabolicdiseases(incl.hypertension, myocardialinfarction,diabetes)心血管及代謝疾病

?Neurologicalconditions(includingstroke,multiplesclerosis, Parkinson’sdisease)神經(jīng)系統(tǒng)疾病

?Chronicmusculoskeletalconditions(incl.LowBackpain, osteoarthritis,rheumatoidarthritis,chronicwidespreadpain andfibromyalgia)慢性運動系統(tǒng)疾?。∪夤趋溃?/p>

?Paedriatricconditions兒科疾病

?Geriatricconditions(incl.frailty,dementia)老年病

Stepwiseapproach(1)階梯式方法?Stepwiseapproach(2)階梯式方法?Step3:Usemodelsofrehabilitationservices:第三階段使用康復服務模型?Implementrehabilitationalongthecontinuumofcare(acute,post-acute,

andlongtermrehabilitation)

沿用連續(xù)性護理實施康復治療

?Levelsofspecialization(fromacutecaretothecommunity) 專業(yè)化水平?Multiprofessionalteamworkasprincipleofstaffing(PRM,PT,OT,SLT,

PsychotherapySocialworkandothers)多專業(yè)混合團隊協(xié)作原則編制人員?Definedinterfaces(incl.transfersystems)界定轉診標準

?Createfinancialsystem(insurances,statesfinancingorothers)建立財務系統(tǒng)?Step4:Defineregions/areasandcalculateconcretedemandofservices

第四階段定義區(qū)域并估算具體服務需求

?Step5:Machdemandwithprinciplesanddefineconcreteplan第五階段：以服務需求為原則，并確定具體計劃Stepwiseapproach(2)階梯式方法?StLevel1aLevel1bLevel2aLevel2bRehabilitationpolicy康復政策HighlyspecializedcentreSpecializedcentreRehabcentreRehabcentreDoctorPTOTS<othersPeers,families,self-helpinggroupsandothersLevel3CasemanagementLevelsofcareprovision護理級別高度專科中心?？浦行目祻椭行目祻椭行牟v管理同伴，家人，自主互助小組及其他Level1aLevel1bLevel2aLevelExample舉例Example舉例?Acuterehabilitationservices:inorcloseto(acute)hospitals急診康復-院內或附近?Post-acuterehabilitationservices:stand-alonerehabilitationfacilities inclosecooperationwithhospitals(highlyspecializedandspecialized)

急診后康復-獨立康復機構-合作醫(yī)院附近?Long-termrehabilitationservice:out-patientormobileservices長期康復-門診或隨診?Servicesforintermittentrehabilitationinchronicconditions:in-patient orday-clinics慢性病不連貫康復服務-入院或日間診療?Vocationalrehabilitationservices:integratedinrehabilitationandvocationalservices

職業(yè)訓練康復服務-康復與職業(yè)訓練集成的服務?Linkstosocialsystem:munityandpeers

與社會系統(tǒng)連接-比如社區(qū)及同伴支持Definitionofservices定義服務?AcuterehabilitationserviceIn-patientordayclinicrehabilitationforpatientswithchronicconditionsFrameworkofRehabServices:dimensions

康復服務的構架—多維度?Serviceprovider:thecategoriestodescribetheproviderincludethe frameworkoftheinstitution(location,organisationetc.)the resources(humanandtechnicalresources)andsomeaspectsof serviceorganisationsuchasprofit-orientationandquality assuranceprograms.Themainquestionsbehindarewhereandin whichcontexttheserviceisdelivered

服務的提供者，最主要的背后問題是在何地，何背景下提供服務?Fundingoftheservice:thecategoriesoffundingdescribethemainsources ofincomeandrefundingofservices.Theyincludethebasic principlesofpaymentsuchasdiagnosis-relatedgroups,per-day paymentofotherformsofservicerefund.Thequestionbehindis whataretheprinciplesoffinancialresources

服務資金來源，背后的問題是融資資金來源問題?Servicedelivery:thecategoriesonservicedeliverycontainthemain strategyappliedtotheusers,aspectsofintensityanddurationof interventionandthewaytheserviceisorganised(e.g.team structure).Itfocusesonthequestionhowtheservicesare deliveredtotheuser服務提供，關注如何向患者提供服務In-patientordayclinicrehabExample舉例Example舉例Example:Floorplanrehabunit康復單元平面圖Example:FloorplanrehabunitExample:rehabunit(foreground)康復單元（前景）Example:rehabunit(foregroundTimeIntensity強度Acutecare急診期管護Post-acuteCare后急診期管護Lon-termcare長期管護Intermittentrehabilitation(in-patientorday-clinic)Post-acuterehabilitation(in-patient)Communitybasedrehabilitation(out-patient)基于康復的社交Acuterehabilita-tion(inhospital)Prevention預防Healthyliving(integratedindailyliving)Intermittentintensiveprevention(in-patient)Integrativephasemodelofrehabcare

康復管護的綜合階段模型間歇強化預防急診期康復后急診期康復間歇性康復TimeIntensity強度AcutecarePost-TimeIntensity強度Acutecare急診期管護Post-acuteCare后急診期管護Lon-termcare

長期管護Intermittentrehabilitation(in-patientorday-clinic)Post-acuterehabilitation(in-patient)Communitybasedrehabilitation(out-patient)基于康復的社交Acuterehabilita-tion(inhospital)Prevention預防Healthyliving(integratedindailyliving)Integratedphasemodelofrehabilitationcare(agreedqualitystandards)協(xié)定質量標準Intermittentintensiveprevention(in-patient)Integrativephasemodelofrehabcare

康復管護的綜合階段模型間歇強化預防間歇性康復后急診期康復急診期康復TimeIntensity強度AcutecarePost-Possibleconcreteprojects可能的具體項目?Designarehabilitationsystemmodelinadefinedregion(project)

在特定區(qū)域內設計一套康復系統(tǒng)模型?

Createanacademyforrehabilitationpersonnel(German-ChineseRehabilitationAcademy)為康復從業(yè)人員建立“德-中康復學院”?Planandrealizerehabilitationserviceforspecificdemandsortarget

groups計劃并實行針對特定需求及目標群體的康復服務

?leadersandmanagers面向領導及管理者

?factoriesorindustries面向工廠或工業(yè)街

?childrenorelderlypeople面向兒童或高齡人群

?specifichealthconditions面向特定健康狀況者?

Planandrealizeacomprehensiverehabilitationserviceinadefinedarea(town,neighborhood)在特定區(qū)域內計劃并實行一套完整的康復服務（城鎮(zhèn)、社區(qū)）?Methods:useGermanmodelorintegratedifferentinternational modelsandtransformintoaChinesemodel方法：利用德國模式或綜合不同國際模式，轉化成中國特色模式Possibleconcreteprojects可能的Challengesandopportunities:

挑戰(zhàn)與機遇

?Whatarethechallengesof planningand implementationprojects?

計劃中和實施中的項目有什么樣的挑戰(zhàn)？

?Whataretheopportunitiesofcollaboration?

合作中的機遇是什么？Challengesandopportunities: Challenges挑戰(zhàn)?Convinceauthorities

取得政府支持?Developrealisticplan改善現(xiàn)實計劃?Allocatemoney(findinvestors)非配資金（找到投資者）?Set-upunits(e.g.inhospitaland/orasrehabilitationcentres)建立康復單位（如建立康復醫(yī)院或建立康復中心）?Set-upprograms(pathwaysandguidelines)建立項目（途徑和方針）?Train(orrecruit)workforce培訓（或引進）從業(yè)人員?Runservice(leadership,qualitymanagement)運行服務（領導，質量管理）Challenges挑戰(zhàn)?ConvinceauthOpportunities機遇Philosophy:developChinesemodelusingGermanstndards理念：發(fā)展德標中用模式?AddedvalueofChineseandGermanexpertise(andarguments)

在中德經(jīng)驗求同存異中增加價值?SynergieswithISPRM’sactivities(WHOcollaborationplan)利用ISPRM活動的協(xié)同效應（WHO合作計劃）?Strongsupportfrominternationalorganisations(andChinesegovernment)來自國際組織及中國官方的強力支持?NetworkofcollaborationpartnersinGermany德國合作伙伴網(wǎng)絡?AccesstoGermanstandards(andexperience)(evenifavailableinGermanlanguageonly),e.g.借鑒德方標準（及經(jīng)驗）（即使僅能使用德語交流）?Rulesforacuterehabilitation 急性期康復規(guī)則

?Pathwaysforpostacuterehabilitation 后急性期通道

?Vocationalrehabilitationprograms專業(yè)的康復方案項目

?andothers及其他?Availablenetwork(spiritofcollaborationandmutualunderstanding)行之有效的網(wǎng)絡（合作及理解互信的精神）Opportunities機遇Philosophy:Networks網(wǎng)絡?Germany: 德方

?HannoverMedicalSchool漢諾威醫(yī)學院

?GermanPensioninsurance(withrehabunits)德國養(yǎng)老保險（含康復單元部分）?GermanWorkersAccidentinsurance德國工人意外保險

?ChinabridgeGermany?China: 中方

?NanjingUniversity 南京大學

?TonjiUniversityWuhan 華中科技大學同濟醫(yī)學院武漢

?ChinabridgeChina?International: 國際

?ISPRM(andotherNGO’swithrelationtoWHO)ISPRM（及其他WHO相關合作組織）Networks網(wǎng)絡?Germany: 德方 Outlook展望?Rehabilitationshouldbeimplementedintoallphasesofhealthcare康復應當在健康管護的全階段進行?Theimplementationofhigh-qualityrehabilitationprogramscanimprovefunctioningandqualityoflifeofpatientsaftercardio-surgery高質量康復項目的實施可以改進心臟外科手術后的生活質量及功能?Rehabilitationprogramsalsohavethepotentialtoreducecostsinhealthsystem康復項目同樣具有在健康系統(tǒng)中節(jié)約資源的潛力?Itmakessensetocombinetherehabilitationstrategywithpreventiveprograms康復策略同預防項目相結合具有積極意義?Concepts,standardsandexpertiseexisttodesigngoodrehabilitationprogramsandservice概念、標準及?？茮Q定了是否可以設計出好的康復項目?Morescientificresearchonoutcomesofrehabilitationisneeded,inparticularaftercardio-surgery更多關于康復的科研結果需求增加，特別在心血管術后Vision:developandimplementamodelofcomprehensiverehabilitationcareinonecityorneighbourhood洞見：在單一城市及周邊發(fā)展并實施全面完善的康復管護模式Outlook展望?RehabilitationshChristophGutenbrunner,MD,PhD,ProfessorDepartmentforRehabilitationMedicineCoordinationCentreforRehabilitationResearchHanoverMedicalSchoolD-30625Hannovergutenbrunner.christoph@mh-hannover.deThankyouforyourattention!ChristophGutenbrunner,MD,PhLevel1aLevel1bLevel2aLevel2bRehabilitationpolicy康復政策HighlyspecializedcentreSpecializedcentreRehabcentreRehabcentreDoctorPTOTS<othersPeers,families,self-helpinggroupsandothersLevel3CasemanagementLevelsofcareprovision護理級別高度?？浦行膶？浦行目祻椭行目祻椭行牟v管理同伴，家人，自主互助小組及其他Level1aLevel1bLevel2aLevelAcuteRehabUnit急診/急性期康復單元Otherwardsofhospital院內其他科室病房Post-acuteRehabilitation(out-patient;day-clinic)后急診康復-門診及日間Out-patientRehabilitation門診康復Post-acuteRehabilitation(in-patient)后急診康復-病房IntensiveCareUnit集中管護單元AcuteRehabilitationTeamstakecareofpatients,themedicalfocusisonotherspecialisedcaremedicalfocusisonfunctionalrehabilitationExamplesofinterfaces對接舉例

AcuteRehabUnitOtherwardsofEvidenceofrehabilitationinICUICU病房康復實例EvidenceofrehabilitationinClinicalfieldReviewer/1stauthorStudies(numbersofparticipants)MDTmoreeffective?lowbackpain–multidisciplinarybiopsychosocialinterventionGuzmanJ,200810RCTs(1964)Betterfunction&paincontrolCoronaryheartdiseasemultidisciplinarydiseasemanagementMcAlisterFA,200112(9803)Feweradmitted,bettercontrolofriskfactors.MIrecurrence&survivalunchangedChronicdisablinglungdisease.OutpatientmultidisciplinaryrehabilitationGriffithsTL,20001RCT(200)lowerhospital&homevisitratesbetterwalking&healthstatusHmunityMDTtreatmentversususualcareStewartS19991RCT(200)Feweradmitted,betterdiet&drugcompliance,survivalsameMultiplesclerosis–InpatientMDTKhanF,20088RCTs(747)betteractivityparticipation,impairmentunchangedbraininjury–communityMDTversusinformationonlyPowellJ,20021RCT(110)betterthaninformationaloneSevereTBI–MDTversusstandardhospitalcareSemylenJK19981quasi-randomCT(56)Betterclinicaloutcome&carerslessdistressedV.NeumannA.,C.Gutenbrunner&A.Delarque:PositionPaperonTeamWorkinPhysical&RehabilitationMedicineEvidenceofteam-integratedrehabilitation

綜合團隊康復實例ClinicalfieldReviewer/1stau

GerdesNetal.:DiePROTOS-Studie.Steinkopff2000Evidenceofrehabinchronicconditions慢性病康復實例

GerdesNetal.:DiePROTOS-SGutenbrunneretal.:PhysMedRehabKuror2001;12:272-283EvidenceofrehabinchronicconditionsGutenbrunneretal.:Evidence-28%-23%Evidenceofjoborientatedprevention面向工作者的預防實例DaysDaysonsick-list:otherdiagnosesDaysonsick-list:JobRehabdiagnosesTotalnumberofdaysonsick-listbeforeJobRehabafterJobRehab-28%-23%EvidenceofjoborientSystematicapproachtoimplementrehabilitationinhealthsystems–collaborationbetweenChinaandGermany完成健康體系中的康復醫(yī)學的系統(tǒng)化處理方法-中德合作

ChristophGutenbrunnerChristophGutenbrunner,MD,PhD,ProfessorDepartmentforRehabilitationMedicineCoordinationCentreforRehabilitationResearchHanoverMedicalSchoolD-30625Hannovergutenbrunner.christoph@mh-hannover.deSystematicapproachtoimplemeOverview內容概要?Arguments:whyshouldweworkontheimplementationof rehabilitationservices?論證：為什么我們應當致力于康復服務的實行？?Conceptualapproach:howtoanalyse,plananimplement rehabilitationservices概念性的探討：如何分析，計劃康復服務的實行?Challengesandopportunities: 挑戰(zhàn)與機遇

?Whatarethechallengesofplanningandimplementation projects?計劃和和實行方案會有著怎樣的挑戰(zhàn)?Whataretheopportunitiesofcollaboration?相互合作會帶來什么樣的機遇Overview內容概要?Arguments:whyArguments:whyshouldweworkontheimplementationof rehabilitationservices?論證：為什么我們應當致力于康復服務的實行？Arguments:whyshouldwework?TheInternationalClassificationofFunctioning,DisabilityandHealth (2001)國際健康功能與身心障礙分類系統(tǒng)?UN-ConventionfortheRightsofPeoplewithDisabilities(2006)聯(lián)合國殘疾人權利公約?WorldReportonDisability(2011)

世界殘疾報告?The“InternationalPerspectivesofSpinalCordInjury”Report(2013)脊髓損傷國際展望報告?ResolutionWHA66.9?Disability“(2013)世界衛(wèi)生大會66.9號殘疾決議?TheWHOGlobalDisabilityActionPlan?BetterHealthforallpeople withdisabilities2014-2021“(2014)世衛(wèi)組織2014–2021年全球殘疾問題行動計劃：增進所有殘疾人的健康Theinternational“normative”approach國際”標準化“?TheInternationalClassificaTheUN-CRPD

(2006)聯(lián)合國殘疾人權力公約?Article26:HabilitationandRehabilitation ?StatesPartiesshalltakeeffectiveandappropriate measures,includingthroughpeersupport,toenable personswithdisabilitiestoattainandmaintain maximumindependence,fullphysical,mental,social andvocationalability,andfullinclusionand participationinallaspectsoflife.Tothatend,States Partiesshallorganize,strengthenandextend comprehensivehabilitationandrehabilitation servicesandprogrammes,particularlyintheareas ofhealth,employment,educationandsocial services,(…)第26條：適應訓練和康復締約國應當采取有效和適當?shù)拇胧?，包括通過殘疾人相互支持，使殘疾人能夠實現(xiàn)和保持最大程度的自立，充分發(fā)揮和維持體能、智慧、社會和職業(yè)能力，充分融入和參與生活的各個方面。為此目的，締約國應當組織、加強和推廣綜合性適應訓練和康復服務和方案，尤其是在醫(yī)療衛(wèi)生、就業(yè)、教育和社會服務方面TheUN-CRPD(2006)聯(lián)合國殘疾人權力公約?ActionPlan:objectives行動計劃：三大目標(1)

toremovebarriersandimproveaccesstohealthservicesand programmes1)清除障礙并提高衛(wèi)生服務和規(guī)劃的可及性(2)

tostrengthenandextendrehabilitation,habilitation,assistive technology,assistanceandsupportservices,andcommunity- basedrehabilitation(2)加強和推廣康復、適應訓練、輔助技術、援助和支持性服務以及以社區(qū)為基礎的康復(3)tostrengthencollectionofrelevantandinternationallycomparabledataondisabilityandsupportresearchondisabilityand

relatedservices

(3)加強收集殘疾方面國際上可對比的相關數(shù)據(jù)，并支持關于殘疾和相關服務的研究ActionPlan:objectives行動計劃：三大TheWHOGlobalDisabilityActionPlan

(2014)世衛(wèi)組織全球殘疾問題行動計劃?Objective2:tostrengthenandextendrehabilitation,habilitation, assistivetechnology,assistanceandsupportservices,and community-basedrehabilitation目標2:加強和推廣康復、適應訓練、輔助技術、援助和支持性服務以及以社區(qū)為基礎的康復 ?Action2.4:Expandandstrengthenrehabilitationand habilitationservicesensuringintegration,acrossthe continuumofcare,intoprimary(including community),secondaryandtertiarylevelsofthe healthcaresystem,andequitableaccess,including timelyearlyinterventionservicesforchildrenwith disabilities2．4擴大并加強康復和適應訓練服務，確保與持續(xù)照護一起納人初級(包括社區(qū))、二級和三級衛(wèi)生保健系統(tǒng)，并確保公平獲取服務。包括為殘疾兒童及時提供早期干預服務TheWHOGlobalDisabilityActiTheWHOGlobalDisabilityActionPlan

(2014)?ProposedinputsforMemberStates: ?Reviewexistingrehabilitationandhabilitationprogrammes andservicesandmakenecessarychangesto improvecoverage,effectivenessandefficiency建議會員國開展的工作：審查現(xiàn)有康復規(guī)劃和服務并作出必要的改變以提高覆蓋率、有效性和效率?ProposedinputsfortheSecretariat: ?Supportcountriesinintegratingrehabilitationandhabilitation servicesintothehealthsystem(…) ?Developrelevanttoolsandtrainingpackagestodevelop andstrengthenhabilitationandrehabilitationservices秘書處的工作：支持國家把康復和適應訓練服務納入衛(wèi)生系統(tǒng).制定相關的工具和培訓一攬子計劃，以便發(fā)展和加強適應訓練及康復服務?Proposedinputsforinternationalandnationalpartners: ?Workwithhealthministriestoexpandandstrengthenthe provisionofrehabilitationandhabilitationservices建議國際和國家伙伴開展的工作：與衛(wèi)生部一起開展工作，推廣和加強提供康復服務TheWHOGlobalDisabilityActiHealthaccountsvs.strategiesNoDimensionsofICHA-HCHealthCareStrategies(Stuckietal.)衛(wèi)生保健策略1HC.1:Servicesofcurativecare根治性治療服務Curativecare(curativestrategy)根治治療(根治性策略）2HC.2:Servicesofrehabilitativecare康復治療服務Rehebilitativecare(rehabilitativestrategy)康復治療（康復性策略）3HC.3:Servicesoflong-termnursingcare長期護理服務Maintenancecare(supportivestrategy)保養(yǎng)治療（支持性策略）4HC.4:Ancillaryservicestohealthcare衛(wèi)生保健的附屬服務5HC.5:Medicalgoodsdispensedtoout-patients門診病人的醫(yī)療用品發(fā)放6HC.6:Preventionandpublichealthservices預防與公共衛(wèi)生服務Prevention(preventivestrategy)預防（預防性策略）7HC.7:Healthadministrationandhealthinsurance衛(wèi)生行政與健康保險Healthaccountsvs.strategiesIn-patientordayclinicrehabilitationforpatientswithchronicconditionsLevelstodescriberehabilitation康復的各描述水平Macrolevel宏觀水平Mesolevel中間水平Microlevel微觀水平Healthstrategy,policy健康策略及政策Ser