社区-家庭康复一体化体系的建立

HARP急症室使用率 Impact – change over 2 years
ED Presentations
80 60
% Change
40 20 0 -20 -40 -60 -80
CNP
COPD
PA
CHF
Non-HARP HARP
Estimated annual saving ~1,300 ED presentations

计划针对增加需要：
人口老化 new treatment options; 新法冶疗
an ageing population;
reduced General Practitioner (GP) availability;
residential care bed shortfalls;
DHS funded 2 HARP programs:两科活动计划 Chronic Disease Complex Needs Management Program Program
长期病科

复杂病科
For people whose attendance is related to complex medical and psychosocial conditions
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
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
WESTERN REGION HEALTH CENTRE

源化全面照护

多
Work in partnership with clients病友伙伴
HARP Interventions

病人在医院 Invited to participate in program and consent邀请参加 Participation in discharge planning出院前安排服务 Consistent point of contact for client保持联络 Comprehensive assessment in the home全面家居需要评估 Development of individual care plans which include: 个别计划：
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?
(N= 57)*
24% 33%
37% 62%
17.2% 23.3%
88% 92%
Reduced admissions 入医院率
Reduced bed days 入住医院
33%
68%
29.8%
92%
* N.B. Total recruited patients = COPD (117), CHF (63), Paed Asthma (137).
订期评核服务和需要
Introducing (Phyllis) 实证

80 year old lady老人女仕 Twice widowed单人
80岁


Lives alone独居
7 children家人
7个
Care Plan

家庭医生Linked in with regular GP
老人科专家Medical history reviewed by HARP Geriatrician 家居服务HACC referral – meals and home help 院舍评估申请ACAS Assessment, waitlisted for CACP 记忆诊所Referred to Memory Clinic 小区职业冶疗O.T home assessment 小区物理冶疗Physiotherapy assessment 小区医护RDNS medication management review

2001-2005 费用是 1亿5百万元
WESTERN REGION HEALTH CENTRE
HARP

A mowenku.baidu.comel of care that involves hospitals and community agencies working in partnership to address the problem of increasing demand on hospital services
Client contacted whilst in hospital

服务流程


知识讲解 Medication management药物管理 Service referrals服务安排
Client education
Plans are reviewed and evaluated regularly
社区-家庭康复一体化体系的建立: 链接医院与社区
Linking Hospital with Community
With a HARP Approach
Wilfred Kwok郭伟权 Physiotherapist, Ergonomist, Master Trainer Melbourne AUSTRALIA
Disease Self Management自我管理疾病 Exercise Habit Modification运动习惯

Effective Exercise Prescription运动处方
WESTERN REGION HEALTH CENTRE
Contents:

Hospital Risk Admission Program 医院风险计划
For people whose attendance is related specifically to COPD肺疾病 Heart failure/angina
心脏疾病

多类疾病及精神问题
Paediatric asthma
孩童哮喘
Western HARP Consortium-Partnership Approach
医生数量

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 selfmanagement strategies 自我管理 individually tailored care 个别目标
WESTERN REGION HEALTH CENTRE
Contributors to success


成功因素
Partnership approach
合作
注重 Created a clear statement of intent清楚
Commitment to the model at all levels Project governance model through to clinical advisory groups
政府及医疗推动

Decisions are based on evaluation of data
分释数据
HARP Model of care服务模式

Care Facilitator assists clients navigation of the health care system服务引导员 Seamless care across the continuum无段式服务
HARP – What have we learnt?

计划经验
Consistent communication with patients and service providers
across the continuum of care. 沟通 Timely flagging of issues relating to patient management. 准
各类小区服务机构及组织
PACFU
Post Acute Care Facilitation Unit
WESTERN REGION HEALTH CENTRE
The Victorian Public Health Care Award for the “ most outstanding metropolitan ambulatory health care provider of the year” for 2005 服务奖项


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
WESTERN REGION HEALTH CENTRE
HARP was created to address sustained increases in demand on the hospital system.
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
HARP入住医院改变 Impact – change over 2 yrs
Bed-Days
60 40
% Change
20 0 -20 -40 -60 -80 CNP COPD PA CHF Non-HARP HARP
Estimated annual saving ~3,100 ED presentations

时准确管理

Assisting patients to follow their own individualised management plan. 帮助制定个人式管理 The importance of involving patients and their families/carers in the decisions relating to their management. 与家人和照

护者有共释
HARP Outcomes
结果
急症医疗
CNP
(N=126)
Use of Acute Health Services
Pre v postrecruitment usage
Reduced ED attendances 急症门诊
COPD
(N=78)*
CHF
(N=37)*
Paed. Asthma



All interventions based on evidence实正为本 Comprehensive assessment to identify needs and gaps in services全面分释服务需要
Multidisciplinary approach to achieve client centred goals
WESTERN REGION HEALTH CENTRE
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.