1、Systematic approach to implement rehabilitation in health systems Professor Christoph Gutenbrunner, MD, PhDPost congress Tour on Rehabilitation TopicsHannover June 23rd, 2015Systematic approach to implement rehabilitation in health systems collaboration between China and Germany完成完成健康体系中的康复医学的系统化处理方
2、法健康体系中的康复医学的系统化处理方法-中德合作中德合作Christoph GutenbrunnerChristoph Gutenbrunner, MD, PhD, Professor Department for Rehabilitation MedicineCoordination Centre for Rehabilitation ResearchHanover Medical SchoolD-30625 Hannovergutenbrunner.christophmh-hannover.de Systematic approach to implement rehabilitation
3、 in health systems Professor Christoph Gutenbrunner, MD, PhDPost congress Tour on Rehabilitation TopicsHannover June 23rd, 2015Overview 内容概要 Arguments: why should we work on the implementation of rehabilitation services?论证：为什么我们应当致力于康复服务的实行？ Conceptual approach: how to analyse, plan an implement reh
4、abilitation services 概念性的探讨：如何分析，计划康复服务的实行 Challenges and opportunities:挑战与机遇 What are the challenges of planning and implementation projects?计划和和实行方案会有着怎样的挑战 What are the opportunities of collaboration?相互合作会带来什么样的机遇Systematic approach to implement rehabilitation in health systems Professor Christop
5、h Gutenbrunner, MD, PhDPost congress Tour on Rehabilitation TopicsHannover June 23rd, 2015Arguments: why should we work on the implementation of rehabilitation services?论证：为什么我们应当致力于康复服务的实行？Systematic approach to implement rehabilitation in health systems Professor Christoph Gutenbrunner, MD, PhDPos
6、t congress Tour on Rehabilitation TopicsHannover June 23rd, 2015 The International Classification of Functioning, Disability and Health (2001)国际健康功能与身心障碍分类系统 UN-Convention for the Rights of People with Disabilities (2006)联合国残疾人权利公约 World Report on Disability (2011) 世界残疾报告世界残疾报告 The “International Pe
7、rspectives of Spinal Cord Injury” Report (2013)脊髓损伤国际展望报告 Resolution WHA 66.9 Disability“ (2013)世界卫生大会66.9号残疾决议 The WHO Global Disability Action Plan Better Health for all people with disabilities 2014-2021“ (2014) 世卫组织20142021年全球残疾问题行动计划：增进所有残疾人的健康The international “normative” approach国际”标准化“System
8、atic approach to implement rehabilitation in health systems Professor Christoph Gutenbrunner, MD, PhDPost congress Tour on Rehabilitation TopicsHannover June 23rd, 2015The UN-CRPD (2006) 联合国残疾人权力公约 Article 26: Habilitation and Rehabilitation States Parties shall take effective and appropriate measur
9、es, including through peer support, to enable persons with disabilities to attain and maintain maximum independence, full physical, mental, social and vocational ability, and full inclusion and participation in all aspects of life. To that end, States Parties shall organize, strengthen and extend co
10、mprehensive habilitation and rehabilitation services and programmes, particularly in the areas of health, employment, education and social services, ()第26条：适应训练和康复缔约国应当采取有效和适当的措施，包括通过残疾人相互支持，使残疾人能够实现和保持最大程度的自立，充分发挥和维持体能、智慧、社会和职业能力，充分融入和参与生活的各个方面。为此目的，缔约国应当组织、加强和推广综合性适应训练和康复服务和方案，尤其是在医疗卫生、就业、教育和社会服务方
11、面Systematic approach to implement rehabilitation in health systems Professor Christoph Gutenbrunner, MD, PhDPost congress Tour on Rehabilitation TopicsHannover June 23rd, 2015Action Plan: objectives行动计划：三大目标(1) to remove barriers and improve access to health services and programmes1)清除障碍并提高卫生服务和规划的可
12、及性(2) to strengthen and extend rehabilitation, habilitation, assistive technology, assistance and support services, and community-based rehabilitation(2)加 强和推广康 复 、适应训 练 、辅助技术 、援 助和支持性服务 以及 以社 区为基础 的康复(3) to strengthen collection of relevant and internationally comparable data on disability and supp
13、ort research on disability and related services (3)加 强 收集 残疾 方 面 国际上 可对 比的相 关 数 据 ，并支持关于残疾和相关服务的研究Systematic approach to implement rehabilitation in health systems Professor Christoph Gutenbrunner, MD, PhDPost congress Tour on Rehabilitation TopicsHannover June 23rd, 2015The WHO Global Disability Ac
14、tion Plan (2014)世卫组织全球残疾问题行动计划世卫组织全球残疾问题行动计划 Objective 2: to strengthen and extend rehabilitation, habilitation, assistive technology, assistance and support services, and community-based rehabilitation 目标2:加 强和推广康 复 、适应训 练 、辅助技术 、援 助和支持性服务 以及 以社 区为基础 的康复 Action 2.4: Expand and strengthen rehabilita
15、tion and habilitation services ensuring integration, across the continuum of care, into primary (including community), secondary and tertiary levels of the health care system, and equitable access, including timely early intervention services for children with disabilities 24扩大并加强康复和适应训练服务 ，确保 与持续 照
16、护一起纳人初级(包括社区)、二级和三级卫生保健系统，并确保公平获取服务。包括为残疾儿童及时提供早期干预服务Systematic approach to implement rehabilitation in health systems Professor Christoph Gutenbrunner, MD, PhDPost congress Tour on Rehabilitation TopicsHannover June 23rd, 2015The WHO Global Disability Action Plan (2014) Proposed inputs for Member S
17、tates: Review existing rehabilitation and habilitation programmes and services and make necessary changes to improve coverage, effectiveness and efficiency建议会 员国开展 的工作：审查现有康复规划和服务并作出必要的改变以提高覆盖率、有效性和效率 Proposed inputs for the Secretariat: Support countries in integrating rehabilitation and habilitati
18、on services into the health system () Develop relevant tools and training packages to develop and strengthen habilitation and rehabilitation services秘书处的工作：支持国家把康复和适应训练服务纳入卫生系统.制定相关的工具和培训一揽子计划，以便发展和加强适应训练及康复服务 Proposed inputs for international and national partners: Work with health ministries to ex
19、pand and strengthen the provision of rehabilitation and habilitation services 建议国 际和 国家伙伴开展 的工 作：与卫生部一起开展工作，推广和加强提供康复服务Systematic approach to implement rehabilitation in health systems Professor Christoph Gutenbrunner, MD, PhDPost congress Tour on Rehabilitation TopicsHannover June 23rd, 2015Health
20、accounts vs. strategiesNoDimensions of ICHA-HCHealth Care Strategies (Stucki et al.)卫生保健策略1HC.1: Services of curative care根治性治疗服务Curative care (curative strategy)根治治疗(根治性策略）2HC.2: Services of rehabilitative care康复治疗服务Rehebilitative care (rehabilitative strategy)康复治疗（康复性策略）3HC.3: Services of long-ter
21、m nursing care长期护理服务Maintenance care (supportive strategy)保养治疗（支持性策略）4HC.4: Ancillary services to health care卫生保健的附属服务5HC.5: Medical goods dispensed to out-patients门诊病人的医疗用品发放6HC.6: Prevention and public health services预防与公共卫生服务Prevention (preventive strategy)预防（预防性策略）7HC.7: Health administration an
22、d health insurance卫生行政与健康保险Systematic approach to implement rehabilitation in health systems Professor Christoph Gutenbrunner, MD, PhDPost congress Tour on Rehabilitation TopicsHannover June 23rd, 2015In-patient or day clinic rehabilitation for patients with chronic conditionsLevels to describe reha
23、bilitation康复的各描述水平Macro level宏观水平Meso level中间水平Micro level微观水平Health strategy, policy 健康策略及政策Service provision, concepts 服务分配及慨念Health condition & functional level (B)Health condition & functional level (A)健康条件及功能水平（A).Systematic approach to implement rehabilitation in health systems Professor Chris
24、toph Gutenbrunner, MD, PhDPost congress Tour on Rehabilitation TopicsHannover June 23rd, 2015TimeIntensity强度Acute care急性急性治疗治疗Post-acute care急性期治疗急性期治疗Lon-term care长期治疗长期治疗Intermittent rehabilitation (in-patient or day-clinic)间断性康复（门诊或日间诊所）Post-acurte rehabilitation (in-patient) 急性期后康复（住院病人）Communit
25、y based rehabilitation (out-patient)以社区为基础的康复（门诊病人）Acute rehabilita-tion (in hospital)急性康复（院内）Integrative phase model of rehab care康复治疗的整合分期模式Gutenbrunner C, Meyer T, Stucki G: : Am J Phys Med Rehabil 2011; 90: 521-525 Systematic approach to implement rehabilitation in health systems Professor Chris
26、toph Gutenbrunner, MD, PhDPost congress Tour on Rehabilitation TopicsHannover June 23rd, 2015Level 4: Multi-professional rehabilitation services水平4多专业性康复服务Level 1: families, peers, etc. 水平1：家庭，病友等等Level 3: PRM, specialized PT, OT etc.水平3：康健医学，专业理疗师，职业治疗师等等Level 2: primary care physicians, PT, OT, et
27、c.水平2：初级护理医生，理疗师，职业治疗师等等Coordinated referral systems (PRM as advisor and coordinator)PRM delivered servicesPRM as trainerLevel 5: highly specialized rehabilitation services (SCI, TBI)水平5高专业化的康复服务（脊髓创伤，脑创伤Levels of specialization 康康复专业水平Systematic approach to implement rehabilitation in health system
28、s Professor Christoph Gutenbrunner, MD, PhDPost congress Tour on Rehabilitation TopicsHannover June 23rd, 2015Community Based Rehabilitation基于社区的康复Gutenbrunner C (2014): submittedSystematic approach to implement rehabilitation in health systems Professor Christoph Gutenbrunner, MD, PhDPost congress
29、Tour on Rehabilitation TopicsHannover June 23rd, 2015The health systems approach卫生系统探讨 Rehabilitation can be seen as a health strategy it also is described as “a set of measures”康复可被视为健康战略也可描述成”一揽子计划” Rehabilitation should be integrated in acute, post-acute and long-term care康复应被整合于急性期,急性期后及长期性治疗中 R
30、ehabilitation should be integrated in primary, secondary and tertiary levels of health care services康复应被整合于医疗服务的一级至三级水平中 Multi-professional rehabilitation services need high standard of service provision including resources such as facilities, technical equipment and human resources 多专业性康复服务需要高标准的服务
31、供给,包括设施,技术设备及人力资源Systematic approach to implement rehabilitation in health systems Professor Christoph Gutenbrunner, MD, PhDPost congress Tour on Rehabilitation TopicsHannover June 23rd, 2015The individual approach (examples)病人个人探讨(举例) Patients with long term mechanical ventilation will develop cont
32、ractures, loose ventilation capacity, develop muscle atrophy, loose circulatory capacity, are in risk of pneumonia and thrombosis and others 机械通气患者常会发展有气管痉挛,肺活量降低,肌肉萎缩,循环血量降低等并发症,处于发生肺炎,血栓及其他的危险下. Patients after stroke will loose opportunity to induce neuroplasticity if rehabilitation does not start
33、 immediately after incident 脑卒中病人若在事件后未立即进行康复治疗,神经可塑性引导的可能性讲会降低 Patients with musculo-skeletal pain syndromes are at risk do develop chronic generalised pain syndromes if primary source of pain is not treated sufficiently肌肉骨骼疼痛症患者如疼痛的首因未被有效治疗,将可能发展成为慢性广泛性疼痛综合征. Patients with chronic health condition
34、s are at risk to be unfit for work if rehabilitation is lacking 慢性疾病患者常可被危及无法适应于工作,如果康复医疗缺失的话 Lack of rehabilitation is a health risk, threat to develop disability缺失康复是一个健康风险,甚至可威胁发展至残疾Systematic approach to implement rehabilitation in health systems Professor Christoph Gutenbrunner, MD, PhDPost con
35、gress Tour on Rehabilitation TopicsHannover June 23rd, 2015Economic & development approach (arguments)经济与发展探讨(论证) Lack of rehabilitation increase costs of health care and social compensation, 缺少康复会导致健康医疗费用的增长及社会补偿e.g. 例如 length of stay in ICUs an in hospital will be longerICU时间将会增加 outcomes of inter
36、ventions (e.g. surgery) will be poorer 干预手段(如外科手术)的结果变差the prevalence of disability will be higher致残发生率增加 Contribution of individuals to society (and social productivity) will be lower个人对社会(和社会生产力)的贡献减少 Lack of rehabilitation is an economic and developmental risk, e.g. disability without rehabilitat
37、ion is a burden for health systems Lack of employees (esp. of high education) harms developmental processes缺少康复是一个经济和发展危险因素，例如无康复医疗的残疾会成为卫生系统的负担。缺少被雇佣者（尤其受过高等教育）会损害发展过程 The provision of rehabilitation services may also be a business康复服务的分配也可成为Systematic approach to implement rehabilitation in health
38、 systems Professor Christoph Gutenbrunner, MD, PhDPost congress Tour on Rehabilitation TopicsHannover June 23rd, 2015Conceptual approach: how to analyse, plan an implement rehabilitation services概念方法：如何分析，计划开展康复服务Systematic approach to implement rehabilitation in health systems Professor Christoph G
39、utenbrunner, MD, PhDPost congress Tour on Rehabilitation TopicsHannover June 23rd, 2015Stepwise approach (1) 阶梯式方法 Step 1: Agreement on basic principles (e.g. UN-CRPD, WRD, WHA Resolution 66.9, Disability action plan) 第一阶段 达成基本共识 Step 2: Analysis of the burden and major causes of disability: 第二阶段 残障
40、的主要原因及难点分析 Traffic accidents and other trauma (incl. spinal cord injury,traumatic brain injury, multiple trauma)交通事故及其他外伤 Cardiovascular and metabolic diseases (incl. hypertension, myocardial infarction, diabetes)心血管及代谢疾病 Neurological conditions (including stroke, multiple sclerosis, Parkinsons dise
41、ase)神经系统疾病 Chronic musculoskeletal conditions (incl. Low Back pain, osteoarthritis, rheumatoid arthritis, chronic widespread pain and fibromyalgia) 慢性运动系统疾病（肌肉骨骼） Paedriatric conditions 儿科疾病 Geriatric conditions (incl. frailty, dementia) 老年病Systematic approach to implement rehabilitation in health s
42、ystems Professor Christoph Gutenbrunner, MD, PhDPost congress Tour on Rehabilitation TopicsHannover June 23rd, 2015Stepwise approach (2)阶梯式方法 Step 3: Use models of rehabilitation services:第三阶段 使用康复服务模型 Implement rehabilitation along the continuum of care (acute, post-acute, and long term rehabilitat
43、ion) 沿用连续性护理实施康复治疗 Levels of specialization (from acute care to the community) 专业化水平 Multiprofessional teamwork as principle of staffing (PRM, PT, OT, SLT, Psychotherapy Social work and others) 多专业混合团队协作原则编制人员 Defined interfaces (incl. transfer systems) 界定转诊标准 Create financial system (insurances, st
44、ates financing or others) 建立财务系统 Step 4: Define regions/areas and calculate concrete demand of services 第四阶段 定义区域并估算具体服务需求 Step 5: Mach demand with principles and define concrete plan 第五阶段：以服务需求为原则，并确定具体计划Systematic approach to implement rehabilitation in health systems Professor Christoph Gutenbrun
45、ner, MD, PhDPost congress Tour on Rehabilitation TopicsHannover June 23rd, 2015Level 1aLevel 1bLevel 2aLevel 2bRehabilitation policy 康复政策Highly specialized centreSpecialized centreRehab centreRehab centreDoctorPTOTS<othersPeers, families, self-helping groups and othersLevel 3Case managementLevels
46、of care provision 护理级别高度专科中心专科中心康复中心康复中心病历管理同伴，家人，自主互助小组及其他Systematic approach to implement rehabilitation in health systems Professor Christoph Gutenbrunner, MD, PhDPost congress Tour on Rehabilitation TopicsHannover June 23rd, 2015Example 举例Systematic approach to implement rehabilitation in health
47、 systems Professor Christoph Gutenbrunner, MD, PhDPost congress Tour on Rehabilitation TopicsHannover June 23rd, 2015 Acute rehabilitation services: in or close to (acute) hospitals 急诊康复-院内或附近 Post-acute rehabilitation services: stand-alone rehabilitation facilities in close cooperation with hospita
48、ls (highly specialized and specialized) 急诊后康复-独立康复机构-合作医院附近 Long-term rehabilitation service: out-patient or mobile services 长期康复-门诊或随诊 Services for intermittent rehabilitation in chronic conditions: in-patient or day-clinics 慢性病不连贯康复服务-入院或日间诊疗 Vocational rehabilitation services: integrated in rehab
49、ilitation and vocational services 职业训练康复服务-康复与职业训练集成的服务 Links to social system: e.g. community and peers 与社会系统连接-比如社区及同伴支持Definition of services 定义服务Systematic approach to implement rehabilitation in health systems Professor Christoph Gutenbrunner, MD, PhDPost congress Tour on Rehabilitation TopicsH
50、annover June 23rd, 2015In-patient or day clinic rehabilitation for patients with chronic conditionsFramework of Rehab Services: dimensions康复服务的构架多维度 Service provider: the categories to describe the provider include the framework of the institution (location, organisation etc.) the resources (human a
