上海市居家安宁疗护服务阻碍因素分析

目的探索上海市居家安宁疗护服务开展的阻碍因素,明确解决这些因素的优先顺序和可行性,为推动居家安宁疗护服务开展提供参考。方法采用概念图法作为方法学指导:通过质性访谈和文献回顾,探索影响居家安宁疗护服务开展的阻碍因素;对阻碍因素进行分类,并对解决每个因素的优先度和可行性进行评分;通过多维尺度分析和层次聚类分析形成概念图。结果共有50名来自社区卫生服务中心和卫生管理部门的人员参加。通过访谈和文献回顾获得61个阻碍因素,层次聚类分析分为5类:员工能力和实践场所(优先级=4.93,可行性=4.38);服务设计(优先级=5.08,可行性=4.30);医疗费用和工作酬劳(优先级=5.62,可行性=4.40);患者与家属的知识和态度(优先级=5.07,可行性=4.27);其他因素(优先级=4.42,可行性=3.69)。结论综合考虑5个聚类解决的优先度和可行性,最应优先解决且具有较高可行性的是医疗费用和工作酬劳问题。建议出台相关政策,保障专项资金的落实,建立合理的服务收费标准,并适当提高工作人员酬劳,以鼓励医护人员积极投入居家安宁疗护服务中。     

Digital health technologies for osteopaths and allied healthcare service providers: A scoping review

BackgroundDigital health technologies are poised to revolutionise the healthcare industry by improving accessibility to services and patient outcomes. The novel coronavirus disease-19 (COVID-19) pandemic has presented unprecedented challenges for the delivery of allied healthcare and has catalysed rapid adoption of telehealth. As such, allied healthcare consumers and providers stand to benefit from the capabilities of the digital health movement, ultimately justifying a scoping review of current and emerging technologies.ObjectiveTo provide decision makers with up-to-date information on the allied health applications of new and emerging digital health technologies; their evidence of efficacy, scope of use, and limitations.MethodsA scoping review of the literature was conducted, guided by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews. To synthesise original research, MEDLINE, CINAHL, and EMBASE databases were searched from 2010 to June 2020 and reference lists were examined for randomised control trials analysing the efficacy of these technologies in allied health applications.ResultsA total of 14 articles were included with a focus on common musculoskeletal conditions managed by allied health service providers. Studies were selected for data extraction after abstract and full-text screening by three independent reviewers. The results of this review indicate that telehealth technology effectively monitors and progresses patient care, while mobile health applications provide remote support and enable data collection.ConclusionEmerging trends suggest that digital technologies serve as promising adjuncts to allied healthcare. Further research is warranted regarding the safety and efficacy of digital health technologies in this context.     

医院社区多学科联动慢性伤口居家护理云平台的构建及实施

目的 构建基于互联网的医院-社区慢性伤口多学科联合居家护理服务模式,解决居家慢性伤口患者护理的难点。 方法 构建医院-社区多学科联动慢性伤口居家护理云平台。患者在线申请,医院专科护士和社区护士分阶段整合多学科诊疗意见后联合实施居家伤口护理,社区护士负责后续的居家护理,平台定期随访。 结果 实施6个月,为辖区内的137例患者提供线上咨询服务,其中8例接受了医院-社区联合居家护理服务,社区护士提供后续上门护理服务及随访36例次。 结论 医院-社区多学科联动慢性伤口居家护理云平台整合了医院和社区服务中心资源,一定程度上解决了慢性伤口患者居家服务需求与服务供给矛盾。     

Telemedicine in the COVID-19 era: Taking care of children with obesity and diabetes mellitus

Severe acute respiratory syndrome coronavirus 2 infection was declared a pandemic in January 2020. Since then, several measures to limit virus transmission have been imposed; among them, home confinement has been the most severe, with drastic changes in the daily routines of the general population. The “stay at home” rule has impaired healthcare service access, and patients with chronic conditions were the most exposed to the negative effects of this limitation. There is strong evidence of the worsening of obesity and diabetes mellitus in children during this period. To overcome these issues, healthcare providers have changed their clinical practice to ensure follow-up visits and medical consultation though the use of telemedicine. Telemedicine, including telephone calls, videocalls, data platforms of shared telemedicine data platforms mitigated the negative effect of pandemic restrictions. Published evidence has documented good metabolic control and weight management outcomes in centers that performed extensive telemedicine services last year during the pandemic. This review discusses studies that investigated the use of telemedicine tools for the management of pediatric obesity and diabetes.     

Chronic kidney disease risk reduction in a Hispanic population through pharmacist-based disease-state management

The purpose of this study was to evaluate the ability of a pharmacist-based disease-state management service to improve the care of indigent, predominately Spanish-speaking patients with diabetes mellitus and common comorbid conditions at high risk for the development of chronic kidney disease (CKD). Patients at high risk for developing CKD who have diabetes at a community health center were placed in a pharmacist-based disease state management service for CKD risk reduction. A residency-trained, bilingual, certified diabetes educator, with a PharmD served as the patient's provider using diagnostic, educational, and therapeutic management services under a medical staff approved collaborative practice agreement. Outcomes were assessed by using national standards of care for disease control and prevention screening. The impact on CKD was shown with a mean A1C decrease of 2% and improvement in the proportion of patients at target goals for blood pressure, A1C, and cholesterol levels and receiving aspirin and angiotensin-converting enzyme inhibitor/angiotensin receptor blocker. A pharmacist-based disease-state management service for CKD risk reduction, care of diabetes, and frequently associated comorbid conditions improved compliance with national standards for diabetes care in a high-risk population.     

Approaches to Self‐Management in Chronic Illness

Management of a chronic medical condition is a complex process and requires coordinated action between healthcare providers and patients. This process is further complicated by the fact that an increasing number of patients suffer from multiple chronic conditions. Self‐management involves active participation of the patients in the everyday care of the symptoms of their illness(es) and medical treatments, as well as maintaining general health and prevention of progression of medical conditions. Managing the psychosocial consequences of illness is also an important component of self‐management. Data have demonstrated that enhancing self‐management improves quality of life, coping, symptom management, disability, and reduces healthcare expenditures and service utilization. To foster self‐management, potential barriers to implementation as well as facilitators and supports for this approach must be acknowledged. In this article, we review various aspects of self‐management in chronic illness, focusing on chronic kidney disease. Better understanding of these concepts will facilitate patient–provider collaboration, improve patient care with increased patient and staff satisfaction, and may ultimately result in better clinical outcomes and enhanced quality of life for both the patients and their families.     

Fragmentation of care as a barrier to optimal ESKD management

Caring for patients with end-stage kidney disease (ESKD) in the United States is challenging, due in part to the complex epidemiology of the disease's progression as well as the ways in which care is delivered. As CKD progresses toward ESKD, the number of comorbidities increases and care involves multiple healthcare providers from multiple subspecialties. This occurs in the context of a fragmented US healthcare delivery system that is traditionally siloed by provider specialty, organization, as well as systems of payment and administration. This article describes the role of care fragmentation in the delivery of optimal ESKD care and identifies research gaps in the evidence across the continuum of care. We then consider the impact of care fragmentation on ESKD care from the patient and health system perspectives and explore opportunities for system-level interventions aimed at improving care for patients with ESKD.     

The ON TRAC model for transitional care of adolescents

This article describes the framework and clinical pathway for ON TRAC (Taking Responsibility for Adolescent/Adult Care), a model of transition care for adolescents with chronic health conditions, as applied to pediatric transplant transition. This model was developed in 1998 at Children's and Women's Health Centre of British Columbia; it provides a multidisciplinary approach to developmentally appropriate transition planning and skill building. The model is youth focused and family centered, and includes stages of transition care on the basis of the developmental stages and capabilities of adolescents. Important considerations for healthcare providers, specific tools for use in clinical settings, and case studies illustrate the use of the ON TRAC model in a pediatric transplant clinic. The ultimate goal of transition in the ON TRAC model is for all adolescents to reach their attainable levels of independence, self-sufficiency, and self-worth while transferring safely and securely into adult healthcare services and adulthood.     

上海市社区医护人员骨质疏松症社区管理实施影响因素的路径分析

目的评估上海市社区医护人员骨质疏松症社区管理实施现状,采用社会生态学理论探讨社区医护人员骨质疏松症社区管理实施的相关影响因素,通过路径分析探究影响因素间的相互作用路径。方法采用方便抽样的方法在上海市20家社区卫生服务中心各抽取42名医护人员共840人进行问卷调查,了解被调查的医护人员骨质疏松症社区管理实施现状及相关影响因素,采用Logistic回归和路径分析对相关影响因素进行分析。结果多因素的Logistic回归结果显示,骨质疏松症危险因素识别技巧(ORm=1.66,95%CI=1.14～2.42)、自我效能(ORm=8.39,95%CI=5.90～11.92)、骨质疏松症社区管理的社区医院环境支持(ORm=1.65,95%CI=1.19～2.29)均能促进社区医护人员骨质疏松症社区管理工作的实施。路径分析结果表明自我效能通过直接效应作用于社区医护人员骨质疏松症社区管理的实施(因子载荷=0.60,P0.001),而社区环境支持(因子载荷=0.11,P0.001)和危险因素识别技巧(因子载荷=0.08,P0.001)可直接也可通过自我效能的中介效应来作用于社区医护人员骨质疏松症社区管理的实施。结论经路径分析发现,社区医护人员骨质疏松症的社区管理的实施是个人、人际及社区三层面因素相互作用影响的,提示在进行干预时,应结合个人与周围环境多层面进行有针对性的干预。     

Models of care for co‐morbid diabetes and chronic kidney disease

Diabetes and chronic kidney disease (CKD) are two of the most prevalent co‐morbid chronic diseases in Australia. The increasing complexity of multi‐morbidity, and current gaps in health‐care delivery for people with co‐morbid diabetes and CKD, emphasize the need for better models of care for this population. Previously, proposed published models of care for co‐morbid diabetes and CKD have not been co‐designed with stake‐holders or formally evaluated. Particular components of health‐care shown to be effective in this population are interventions that: are structured, intensive and multifaceted (treating diabetes and multiple cardiovascular risk factors); involve multiple medical disciplines; improve self‐management by the patient; and upskill primary health‐care. Here we present an integrated patient‐centred model of health‐care delivery incorporating these components and co‐designed with key stake‐holders including specialist health professionals, general practitioners and Diabetes and Kidney Health Australia. The development of the model of care was informed by focus groups of patients and health‐professionals; and semi‐structured interviews of care‐givers and health professionals. Other distinctives of this model of care are routine screening for psychological morbidity; patient‐support through a phone advice line; and focused primary health‐care support in the management of diabetes and CKD. Additionally, the model of care integrates with the patient‐centred health‐care home currently being rolled out by the Australian Department of Health. This model of care will be evaluated after implementation across two tertiary health services and their primary care catchment areas.     

Community-orientated primary health care. The responsibility of the team for the health of the total population

Community-orientated primary health care (COPHC) is presented as a framework for the delivery of primary health care based on the epidemiologically assessed needs of the population. It requires that the health team and the responsible agencies or institutions take upon themselves responsibility for the provision of care in relation to these measured needs of all those persons entitled to the service. This epidemiological diagnosis of community health conditions will include both the measurement of the distribution of health and disease states in the community as well as the possible causes for this distribution--this is in order to plan possible intervention adequately. It is concluded that COPHC is to the advantage of the community, the health team and the health care system.     

Quality indicators for a community‐based wound care centre: An integrative review

The purpose of this review was to identify the role and contribution of community‐based nurse‐led wound care as a service delivery model. Centres increasingly respond proactively to assess and manage wounds at all stages – not only chronic wound care. We conducted an integrative review of literature, searching five databases, 2007–2018. Based on inclusion and exclusion criteria, we systematically approached article selection and all three authors collaborated to chart the study variables, evaluate data, and synthesise results. Eighteen studies were included, representing a range of care models internationally. The findings showed a need for nurse‐led clinics to provide evidence‐based care using best practice guidelines for all wound types. Wound care practices should be standardised across the particular service and be integrated with higher levels of resources such as investigative services and surgical units. A multi‐disciplinary approach was likely to achieve better patient outcomes, while patient‐centred care with strong patient engagement was likely to assist patients' compliance with treatment. High‐quality community‐based wound services should include nursing leadership based on a hub‐and‐spoke model. This is ideally patient‐centred, evidence‐based, and underpinned by a commitment to developing innovations in terms of treatment modalities, accessibility, and patient engagement.     

社区老年患者护理需求的调查研究

目的研究社区老年患者对护理方法和护理方式的需求。方法采用前瞻性开放研究,2010年3月～2010年9月以笔者所在医院服务的586名社区老年患者为调查对象,采用自行设计的统一调查表实施调查,并进行统计学分析。结果护理方法首选医护人员个别指导,其次是社区医护人员讲解示范;社区护理方式首选电话咨询,其次是医护人员家访。结论随着生活水平的提高和社区医疗服务的不断普及,尤其是针对老年患者慢性疾病的社区护理,在老年人群中越来越得到认可和欢迎,因此完善社区护理服务网络,提高服务质量是目前的急需解决的任务和面临的挑战。     

Private payer value initiatives: The Michigan Model

The recent national emphasis on improving value in healthcare delivery has placed increasing responsibility for health care value improvement on individual hospitals through financial incentives. Private Payer Initiatives are partnerships between providers and hospitals with payers that are intended to improve quality and value of health care. Blue Cross Blue Shield of Michigan has been a pioneer in the development and financial support of “The Michigan Model.” The Michigan Model is a is a longstanding multifaceted initiative that has successfully improved quality of healthcare delivery throughout the state through the development of collaborations between providers and acute care hospitals.     

From policy to praxis--a framework for the delivery of district mental health care in KwaZulu-Natal.

This article provides a schema for the provision of mental health care at district level. A framework for service delivery was derived from research conducted by the Community Mental Health Programme (CMHP) into the development of aspects of a district mental health care system in a semi-rural community area in KwaZulu-Natal. Furthermore, information was drawn from interviews with key stakeholders, national and provincial policy documents as well as international experience in the implementation of community-based systems of mental health care.     

A health status and health service utilization study of a peri-urban community in Kwazulu

A community survey was undertaken in a district in Kwazulu, adjacent to Pietermaritzburg. Natal, in order to determine health status and health service utilization patterns at a local level. This low-cost survey was labour-efficient and yielded useful data for the evaluation and planning of local health services. It was found that child health and delivery services were under-utilized while family planning and antenatal care services were comparatively well used. 'Traditional' practitioners' services were used regularly by 51% of the mothers and childminders interviewed. The use of the services of general medical practitioners was less significant. Some 36% of the children under 5 years of age were found to be malnourished, and 29% had conditions requiring medical treatment. The findings of this study indicate that a major discrepancy exists between the local need for health services and utilization of the available services. The introduction of community health workers is proposed as a possible solution.     

Fibromyalgia: an update for oral health care providers.

Fibromyalgia (FM) is a syndrome characterized by chronic widespread pain, stiffness, nonrestorative sleep, fatigue, and comorbid conditions. Fibromyalgia has undergone a major paradigm shift in recent years. It is no longer considered a musculoskeletal disorder per se; rather, it represents one end of a spectrum of disorders characterized by chronic widespread pain. Hence, oral health care providers may be the first to recognize signs and symptoms of this complex disorder and are often consulted to participate in the management of FM patients. This medical management update will review the epidemiology, classification, etiology and pathophysiology, clinical presentation, and therapeutic advances in FM. This review will also highlight issues that are important to the oral health care provider, including orofacial manifestations and dental considerations for patients with FM.     

Staff/bed and staff/patient ratios in South African public sector mental health services.

OBJECTIVES: To document staff/bed and staff/patient ratios in public sector mental health services in South Africa. DESIGN: Cross-sectional survey. METHOD: A questionnaire was distributed to provincial mental health co-ordinators requesting numbers of full-time equivalent (FTE) staff who provide mental health care at all service levels; numbers of psychiatric beds; and numbers of patients who attend outpatient departments, clinics and community health centres. The information was supplemented by consultations with mental health co-ordinators in each of the nine provinces. RESULTS: The staff/bed ratio for the country as a whole was 0.3 staff per bed. For the provinces, the staff/bed ratios were as follows: Eastern Cape 0.30, Free State 0.50, Gauteng 0.22, KwaZulu-Natal 0.34, Mpumalanga 0.89, North-West 0.27, Northern Cape 0.26, Northern Province 0.26, and Western Cape 0.59. For the country as a whole, the staff/bed ratios for each category of staff were as follows: total nursing staff 0.25, occupational therapists 0.01, occupational therapy assistants 0.01, social workers 0.01, community health workers 0.00, psychologists 0.00, intern psychologists 0.00, psychiatrists 0.00, psychiatric registrars 0.01, and medical officers 0.00. The ratio of ambulatory psychiatric service staff to daily patient visits (DPV) for the country as a whole was 0.6. CONCLUSIONS: Staff/bed ratios in South African mental health care are low relative to developed countries. Staff/DPV ratios highlight both the need to develop ambulatory care personnel for mental health care, and problems associated with monitoring the delivery and utilisation of mental health services within an integrated health system at primary level.     

台州市社区护理现状及需求调查

目的了解城镇居民社区护理现状与需求。方法采用自行设计的调查问卷随机对台州市5个社区251户家庭的749名居民和30所社区卫生服务站进行调查。结果69．7％居民有老年慢性疾病护理需求、67．7％有家庭病床和残疾人康复需求、63．2％有急救护理需求、60．2％有上门护理需求；62．0％居民健康理念落后、69．8％居民社区护理观念滞后。健康理念、健康状况、经济收入和文化程度与社区护理需求变量关系显著（均P〈0.01）。30所服务站护士比例占22．9％．非普教中专毕业生占68．2％，无学历占18．2%；均采用以医疗为主、自负盈亏的服务模式。结论对照国内外社区护理发展现状，发现台州市居民的保健需求与社区护理质量矛盾突出，滞后的社区护理理念、社区卫生服务的挪艘制鲐社厌护理右屡．重积超巢取措箍．加以改善．     

PTSD in those who care for the injured

BackgroundPost Traumatic Stress Disorder (PTSD) has become a focus for the care of trauma victims, but the incidence of PTSD in those who care for injured patients has not been well studied. Our hypothesis was that a significant proportion of health care providers involved with trauma care are at risk of developing PTSD.MethodsA system-wide survey was applied using a modified version of the Primary Care PTSD Screen [PC-PTSD], a validated PTSD screening tool currently being used by the VA to screen veterans for PTSD. Pre-hospital and in-hospital care providers including paramedics, nurses, trauma surgeons, emergency medicine physicians, and residents were invited to participate in the survey. The survey questionnaire was anonymously and voluntarily performed online using the Qualtrix system. Providers screened positive if they affirmatively answered any three or more of the four screening questions and negative if they answered less than three questions with a positive answer. Respondents were grouped by age, gender, region, and profession.Results546 providers answered all of the survey questions. The screening was positive in 180 (33%) and negative in 366 (67%) of the responders. There were no differences observed in screen positivity for gender, region, or age. Pre-hospital providers were significantly more likely to screen positive for PTSD compared to the in-hospital providers (42% vs. 21%, P < 0.001). Only 55% of respondents had ever received any information or education about PTSD and only 13% of respondents ever sought treatment for PTSD.ConclusionThe results of this survey are alarming, with high proportions of healthcare workers at risk for PTSD across all professional groups. PTSD is a vastly underreported entity in those who care for the injured and could potentially represent a major problem for both pre-hospital and in-hospital providers. A larger, national study is warranted to verify these regional results.