南京市安宁疗护服务规范

安宁疗护是对疾病终末期患者通过控制痛苦和不适症状,提供身体、心理、社会、精神等方面的照护和人文关怀等服务,来提高生命质量,帮助患者舒适、安详、有尊严地离世。2017年国家卫生健康委员会连发两文:《安宁疗护实践指南(试行)》[1]和《安宁疗护中心基本标准和管理规范(试行)》[2],并在北京、上海、洛阳等地区开展第一批安宁疗护试点工作。在第一批安宁疗护试点工作取得突破性进展后,2019年10月国家卫健委等部门联合印发的“两个《意见》”中均指出要加强安宁疗护服务发展,安宁疗护进入全面推进新局面,并开展了全国第二批安宁疗护试点工作,其中南京市作为第二批安宁疗护试点城市。本规范拟针对安宁疗护的服务模式、服务内容、质量评价制定标准,借鉴国内外各指南标准和实验研究,结合实践经验,归纳总结出符合南京市的安宁疗护标准,以提供更科学、同质化的安宁疗护服务,更好地发挥安宁疗护作用。     

艾滋病患者安宁疗护现状及影响因素的研究进展

晚期艾滋病患者具有身体、心理等多方面的问题,安宁疗护需求高。本文从艾滋病患者安宁疗护的必要性、现状、影响因素进行综述,以期为国内安宁疗护在艾滋病患者中的推进提供依据和指导,为患者提供身体、心理、精神等多方面的照护,提高其生活质量。     

中国老年安宁疗护的研究进展

正老年安宁疗护的核心为尊重生命、关怀生命~[1]。帮助临终患者安静又有尊严地实现"优逝~[2]",真正落实人道主义,以人为本,减少家庭精神压力和经济负担~[3],减少社会医疗资源浪费~[4]。由于疾病本身及治疗的复杂性影响,安宁疗护实施过程常有疾病的多种症状并存~[5]。朱春鹰等~[6]对此提出全人健康模式的概念。目前,安宁疗护相关现象与政策研究已成为研究热点~[7]。安宁疗护的研究从横断面调查逐渐转向干预研究,旨在寻求相对稳定的临床症状及影响因素而找     

天津市养老机构安宁疗护服务满意度调查

目的了解天津市养老机构安宁疗护服务现状,分析养老机构安宁疗护服务现存的问题,并对其未来的发展提出意见和建议。方法选取2016年1月至2017年6月在天津市6所养老机构中去世老人的家属为调查对象。应用中文版家属照护认知量表(FPCS)调查135例去世老人家属对养老机构安宁疗护服务的满意度。采用SPSS 20.0软件进行统计处理。结果中文版家属照护认知量表条目平均分为5.09;得分较低的5个条目为"宗教服务"、"个体化护理方案"、"参与制定护理计划"、"疼痛的控制"、"足够的工作人员";家属最关注的3个条目是"舒适性护理"、"尊重老人"和"疼痛的控制"。结论中文版FPCS问卷调查结果显示,去世老人家属对养老机构安宁疗护服务满意度较高,养老机构应在今后的安宁疗护服务中加强不足方面的建设。     

老年安宁疗护中常见症状的控制

<正>安宁疗护是由医生、护士、心理治疗师、药剂师、宗教人士、志愿者等人组成的专业服务团队,通过早期识别和准确评估等手段,从生理、社会心理和精神方面,为病人提供全人、全家、全程、全队的医疗照顾,从而提高对治愈性治疗已无获益的病人及其家属的生活质量。世界卫生组织(WHO)对安宁疗护的定义为:通过早期识别、评估、控制疼痛等症状的方式,向患有威胁生命疾病的病人和家庭提供服务,缓解其身体、社会心     

江苏省安宁疗护开展情况调研

<正>安宁疗护(临终关怀)是为那些罹患无法治愈疾病的病人提供积极的整体护理,主要通过预防、评估和有效控制疼痛及其他躯体症状,处理心理、社会和精神方面的一系列问题,最大可能地提高病人及其家属的生活质量[1]。国家卫生计生委于2017年1月25日已下发了《关于印发安宁疗护实践指南(实试行)的通知》和关于《印发安宁疗护中心基本标准和管理规范(试行)的通知》。为积极贯彻两个通知精神,有效推动江苏省     

老年安宁疗护中的社会支持

<正>安宁疗护并非是一种治愈疗法,而是一种专注于在病人将要逝世前的几个星期甚至几个月的时间内,减轻其疾病的症状、延缓疾病发展的医疗护理。世界卫生组织指出,对于晚期病人及家庭提供的安宁疗护照顾,是以照料为中心,以维护病人尊严、提高生存质量为目的,其主要任务包括对症治疗、家庭护理、缓解症状、疼痛控制、减少或消除病人的负面情绪[1]。这一过程需要医生、护士、社会工作者、营养师、心理咨询师、志愿者等多学科团队的共同参与。随着我国老龄     

老年临终患者生存期预测

<正>国家卫生和计划生育委员会在2017年1月发布了《安宁疗护实践指南(试行)》,随后在2月连续发布了《安宁疗护中心基本标准(试行)》和《安宁疗护中心管理规范(试行)》,这三个文件为安宁疗护在我国的发展树立了里程碑^[1]。伴随着安宁疗护不断推进和蓬勃发展,临终患者即患有终末期器官衰竭和失智等慢性不可治愈疾病的患者及晚期癌症患者(预估照护生命期≤6个月)的生存期预测备受关注^[2]。对于临终患者,特别是老年人群中的临终患者,     

老年安宁疗护中的心理精神照护

<正>随着医疗水平的不断发展,医生可以通过医疗技术来延长病人的生命,但却并没有充分考虑到这些措施所带来的消极影响,有时也没有顾及到病人本人及家属的心理需求和精神状态。然而,生命并不只有长度,安宁疗护虽然不能延长病人的生存期,但却是改善病人生命质量的合理选择。病人(特别是老年病人)由于长时间受疾病的困扰而产生的不良心理因素已经严重影响到疾病的康复和生活质量的提高[1]。因此,在安宁疗护中,对病人的心理精神照护以及相应临床     

急症入住安宁病房的晚期癌症临终疗护分析

目的了解晚期癌症临终病人以急性症状入住安宁病房的病例,为提供相应的临终疗护提供分析资料。方法采用回顾性调查对2006—2008年入住临汾社区卫生服务中心安宁病房、住院时间在1～30d内的晚期癌症病人的急性症状进行统计分析。结果晚期癌症临终常见病人常见的急性症状主要有：呼吸困难、烦躁、疼痛、恶心、呕吐、便秘。结论晚期癌症病人上述症状普遍存在,应积极采取对应的临终疗护,减轻临终病人的痛苦。     

Ten Things Every Geriatrician Should Know About House Calls

Home‐based primary care (HBPC) is experiencing a reemergence to meet the needs of homebound older adults. This brief review based on existing literature and expert opinion discusses 10 key facts about HBPC that every geriatrician should know: (1) the team‐based nature of HBPC is key to its success; (2) preparations and after‐hour access for house calls are required; (3) home safety for the clinician and patient must be considered; (4) being homebound is an independent mortality risk factor with a high symptom burden; (5) home care medicine presents unique benefits and challenges; (6) a systems‐based approach to care is essential; (7) HBPC is a sustainable model within value‐based care proven by the Department of Veterans Affairs and the Independence at Home Medicare Demonstration Project; (8) HBPC has an educational mission; (9) national organizations for HBPC include American Academy of Home Care Medicine and Home Centered Care Institute; and (10) practicing HBPC is a privilege. HBPC is a dynamic and unique practice model that will continue to grow in the future. J Am Geriatr Soc 67:139–144, 2019.     

Better Access,Quality, and Cost for Clinically Complex Veterans with Home‐Based Primary Care

In successfully reducing healthcare expenditures, patient goals must be met and savings differentiated from cost shifting. Although the Department of Veterans Affairs (VA) Home Based Primary Care (HBPC) program for chronically ill individuals has resulted in cost reduction for the VA, it is unknown whether cost reduction results from restricting services or shifting costs to Medicare and whether HBPC meets patient goals. Cost projection using a hierarchical condition category (HCC) model adapted to the VA was used to determine VA plus Medicare projected costs for 9,425 newly enrolled HBPC recipients. Projected annual costs were compared with observed annualized costs before and during HBPC. To assess patient perspectives of care, 31 veterans and caregivers were interviewed from three representative programs. During HBPC, Medicare costs were 10.8% lower than projected, VA plus Medicare costs were 11.7% lower than projected, and combined hospitalizations were 25.5% lower than during the period without HBPC. Patients reported high satisfaction with HBPC team access, education, and continuity of care, which they felt contributed to fewer exacerbations, emergency visits, and hospitalizations. HBPC improves access while reducing hospitalizations and total cost. Medicare is currently testing the HBPC approach through the Independence at Home demonstration.     

To the hospital and back home again: a nurse practitioner-based transitional care program for hospitalized homebound people

Homebound older adults may receive suboptimal care during hospitalizations and transitions home or to postacute settings. This 2-year study describes a nurse practitioner (NP)-led transitional care program embedded within an existing home-based primary care (HBPC) program. The transitional care pilot program was designed to improve coordination and continuity of care, reduce readmissions, garner positive provider feedback, and demonstrate financial benefits through shorter length of stay, lower cost of inpatient stay, and better documentation of patient complexity. A detailed mixed-methods evaluation was conducted to characterize the hospitalized homebound population and investigate provider feedback and program feasibility, effectiveness, and costs. Length of stay (LOS), case-mix index, and admission-related financial costs were compared before and after the intervention using a pre-post design. Structured focus groups were conducted with inpatient and primary care providers to collect feedback on the usefulness of and satisfaction with the program. The program improved communication between home-based primary care providers and inpatient providers of all disciplines and facilitated the timely and accurate transfer of critical patient information. The intervention failed to decrease hospital LOS and readmission rate significantly for people who were hospitalized. The financial implications were reassuring, although future studies are necessary. This model of a NP-led program may be feasible for enhancing inpatient management and transitional care for older adults in HBPC programs and should be considered to augment the HBPC care model.     

A multidisciplinary program for delivering primary care to the underserved urban homebound: looking back, moving forward

The coming decades will see a dramatic rise in the number of homebound adults. These individuals will have multiple medical conditions requiring a team of caregivers to provide adequate care. Home-based primary care (HBPC) programs can coordinate and provide such multidisciplinary care. Traditionally, though, HBPC programs have been small because there has been little institutional support for growth. Three residents developed the Mount Sinai Visiting Doctors (MSVD) program in 1995 to provide multidisciplinary care to homebound patients in East Harlem, New York. Over the past 10 years, the program has grown substantially to 12 primary care providers serving more than 1,000 patients per year. The program has met many of its original goals, such as helping patients to live and die at home, decreasing caregiver burden, creating a home-based primary care training experience, and becoming a research leader. These successes and growth have been the result of careful attention to providing high-quality care, obtaining hospital support through the demonstration of an overall positive cost-benefit profile, and securing departmental and medical school support by shouldering significant teaching responsibilities. The following article will detail the development of the program and the current provision of services. The MSVD experience offers a model of growth for faculty and institutions interested in starting or expanding a HBPC program.     

The positive financial contribution of home-based primary care programs: the case of the Mount Sinai Visiting Doctors

The coming decade will see a rise in the number of homebound seniors. These vulnerable patients have great difficulty accessing primary care. Home-based primary care (HBPC) can fill this healthcare need. Presently, such programs have been slow to develop, in part because of the perception that they are fiscal liabilities. Using the Mount Sinai Visiting Doctors (MSVD) program, the total financial effect of an HBPC program on an Academic Health Center (AHC) was assessed. A retrospective cohort analysis (n=692, 565 patient years) of Medicare-eligible individuals who were enrolled in the MSVD HBPC program was conducted. Revenues and associated costs for direct physician home care services, inpatient admissions, and outpatient clinic and emergency department visits for 1 calendar year were captured. Sensitivity analyses varying efficiency and cost variables were performed. Total direct cost for HBPC for the patient cohort was $976,350. Direct billing from home visits generated revenues that covered 24% of total direct care costs. Over a 12-month period, the cohort had 398 inpatient admissions and 1,100 non-HBPC outpatient visits, generating an overall contribution to margin of nearly $2.6 million. It is likely that this analysis underestimates the true contribution to margin, because it does not capture patient encounters at specialty clinics not in the Department of Medicine, unaffiliated medical centers, or private community-based practices. Although direct billing for HBPC programs does not generate enough revenue to meet operating costs, they can be significant revenue generators for the wider healthcare system and thus are fiscally worthy of subsidization.     

An exploration of the NHS end of life care programme and its potential use for patients with end-stage systemic sclerosis

Systemic sclerosis is an autoimmune connective tissue disorder with the highest case-specific mortality of the rheumatic disorders (Denton and Black, 1999). Despite recent developments in the treatment of systemic sclerosis, patients are still dying from its complications. Therefore the palliative care needs of patients with end-stage systemic sclerosis must be considered. There is little research into palliative care for patients with systemic sclerosis, but clinical experience suggests the level of care has been dependent upon local resources and the experience of the team responsible for the patient's care. The need for equitable, high-quality palliative care for patients with end-stage systemic sclerosis may be met by current developments in end of life care within the UK. The present paper outlines the NHS end of life care programme (DoH, 2003; NICE, 2003) and uses a case study approach to illustrate its application to palliative care in end-stage systemic sclerosis.     

Met and unmet palliative care needs of people living with HIV/AIDS in Rwanda

The rising number of people living with HIV/AIDS (PLWHA) worldwide has made health care professionals and policy makers search for accessible health care that will meet the needs of people who are suffering from the disease and enhance their quality of life (QoL). This study investigated met and unmet palliative care needs of PLWHA in selected areas in Rwanda. The study sample included 306 participants: PLWHA, health care professionals and coordinators of HIV/AIDS units. Quantitative and qualitative methodologies were used. The data were analysed separately and then triangulated. In the findings, over 50% of PLWHA had symptoms related to HIV/AIDS most of the time, with the most common symptom being pain. Participation in activities of daily living was significantly associated with the health status of PLWHA (p<0.001). The most common perceived palliative care needs of PLWHA were medical needs, psychosocial needs and the need for financial assistance (77%); home-based care (47%); nutritional support (44%); and pain relief and management of other symptoms (43%). Most PLWHA indicated these palliative care needs were unmet, in particular the need for pain relief, symptom management, financial assistance and nutritional support. Over 50% of health care professionals reported they were not trained in palliative care. They indicated that inadequate policy and resources were the main obstacles to the provision of optimal palliative care. Addressing unmet palliative care needs would enhance the QoL of PLWHA. In addition, developing policy related to the provision of palliative care and building the capacity of health care providers is essential for the provision of adequate palliative care services in Rwanda.     

Improving Access to Noninstitutional Long‐Term Care for American Indian Veterans

Home‐based primary care (HBPC) is an effective model of noninstitutional long‐term care developed in the Department of Veterans Affairs (VA) to provide ongoing care to homebound persons. Significant rural populations of American Indians have limited access to services designed for frail older adults. Fourteen Veterans Affairs Medical Centers (VAMCs) initiated efforts to expand access to HBPC in concert with local tribes and Indian Health Service (IHS) facilities. This study characterizes the resulting emerging models of HBPC and co‐management. Using an observational design, key respondent telephone interviews (n = 37) were conducted with stakeholders representing the 14 VAMCs to describe these HBPC programs, and HBPC models were evaluated in relation to VAMC organizational culture as revealed on the annual VA All Employee Survey. Twelve VAMCs independently developed HBPC expansion programs for American Indian veterans, and six different program models were implemented. Two models were unique to collaborations between VAMCs and tribes; in these collaborations, the tribes retained primary care responsibilities. VAMC used the other four models for delivery of care in remote rural areas to all veteran populations, American Indians and non‐Indians alike. Strategies to improve access by reducing geographic barriers occur in all models. Comparing mean VAMC organizational culture ratings, as defined in the Competing Values Framework, revealed significant group differences for one of these six models. Findings from this study illustrate the flexibility of the HBPC program and opportunities for co‐management and expansion of healthcare access for American Indians and non‐Indians, particularly in rural areas.     

Home‐Based Primary Care: Beyond Extension of the Independence at Home Demonstration

The Independence at Home (IAH) Demonstration Year 2 results confirmed that the first‐year savings were 10 times as great as those of the pioneer accountable care organizations during their initial 2 years. We update projected savings from nationwide conversion of the IAH demonstration, incorporating Year 2 results and improving attribution of IAH‐qualified (IAH‐Q) Medicare beneficiaries to home‐based primary care (HBPC) practices. Applying IAH qualifying criteria to beneficiaries in the Medicare 5% claims file, the effect of expanding HBPC to the 2.4 million IAH‐Q beneficiaries is projected using various growth rates. Total 10‐year system‐wide savings (accounting for IAH implementation but before excluding shared savings) range from $2.6 billion to $27.8 billion, depending on how many beneficiaries receive HBPC on conversion to a Medicare benefit, mix of clinical practice success, and growth rate of IAH practices. Net projected savings to the Centers for Medicare and Medicaid Services (CMS) after routine billing for IAH services and distribution of shared savings ranges from $1.8 billion to $10.9 billion. If aligning IAH with other advanced alternative payment models achieved at least 35% penetration of the eligible population in 10 years, CMS savings would exceed savings with the current IAH design and HBPC growth rate. If the demonstration were simply extended 2 years with a beneficiary cap of 50,000 instead of 15,000 (as currently proposed), CMS would save an additional $46 million. The recent extension of IAH, a promising person‐centered CMS program for managing medically complex and frail elderly adults, offers the chance to evaluate modifications to promote more rapid HBPC growth.     

Palliative care: what approaches are suitable in developing countries?

The enormous burden of life‐threatening illnesses, including cancer, human immunodeficiency virus infection, and others, such as sickle cell disease, associated with physical and psychosocial suffering explains the illustrious need for palliative care in developing countries. Despite the demonstrated need, current provision of palliative care in Africa is at best limited, and at worst non‐existent. Access to essential pain medicines, particularly oral morphine, for control of pain is extremely limited and far below the global mean. There is a general lack of government policies that recognize palliative care as an essential component of health care and there is inadequate training for both health care professionals and the general public about palliative care. A public health strategy, as recommended by the World Health Organization (WHO), offers the best approach for translating knowledge and skills into evidence‐based, cost‐effective interventions that can reach everyone in need of palliative care in developing countries.