破解养老难题的基本策略——“五元共构”医养融合模型的建立与分析

老龄化进程的加速发展必然导致养老服务需求量的快速增长,个性化养老服务需求尤其是失能、失智老人在医疗与照护方面的刚性需求显得特别突出,如何有效地满足这些需求已经成为一个社会难题。成都市老年康疗院经过多年的摸索、研究与实践,构建了一套以医养结合为核心理念的＂五元共构＂基本模型。该模型包括老年医疗、老年照护、老年康复、老年健康服务人才培养以及老年健康问题研究5个方面。该模型的发展也面临行业标准欠缺、启动资金大、技术要求高和服务对象支付能力受限等具体困难。     

浙江省高校老年医学教育现状与对策思考

目的调查了解浙江省高校临床医学专业与护理学专业有关老年医学与护理课程的设置情况、继续医学教育项目,为老年医学教育和老年医护人才培养模式的构建提供依据。方法采用自行设计的调查问卷对浙江省14所设置临床医学专业和护理学专业的医学类院校进行书面或官网数据调查,同时取样浙江省继续医学教育网近4年老年医学类项目。结果在本科和专科教育阶段,仅有1所高校开设老年医学选修课程,5所院校开设老年护理课程;在硕士研究生教育阶段,有3所高校招收老年医学相关方向的硕士研究生,1所高校招收老年护理方向的硕士研究生,继续教育项目占比仅为3．4％。结论老年医学与护理教育现状堪忧,严重背离社会发展的需求,应当尽快增设老年医学与老年护理专业,建立老年医学与护理教育体系,完善老年医学人才培养模式。     

One third of a million days of care at home, 1959 to 1975.

Although articles on studies of organized home care programs are numerous, reports of long-term effectiveness of these programs are scanty. While government spokesmen appear to advocate more widespread use of alternatives to hospitalization, there has been serious criticism of the efficiency and accomplishments of home care services. A medically oriented home care program in Saskatoon (population, less than 150 000) has grown steadily over a 16-year period and is now serving a daily average of 200 individuals. All patients have required "hospital-like care" at home and most have not ordinarily been sufficiently mobile during their time in the program to attend hospital outpatient services. Many have required "concentrated care" through daily visits of professional health personnel. The program is designed for the physically ill and disabled and is administered by the major teaching hospital in the city, although it provides services to the whole community. Over one third of the patients referred in recent years had been at home. Almost one half of the patients have undergone satisfactory rehabilitation at home. The program has also proven to be an acceptable alternative to long-term institutional care for the permanently seriously disabled, a large number of whom are elderly. The program has been able to operate at considerably less cost to the public than inpatient (hospital or institutional) services would have entailed.     

基于CiteSpace的老年口腔健康研究可视化分析

目的 采用CiteSpace软件分析我国近10年老年口腔健康现状、热点及趋势,旨在为后期老年口腔健康的干预策略提供参考。方法 对中国知网、万方及维普数据库中2012年1月1日至2022年10月31日发表的老年口腔健康的相关文献进行搜索,通过CiteSpace软件分析发文的年代趋势、作者、合作机构、关键词。结果 共纳入文献291篇,近10年来年均发文量总体呈相对平稳趋势,作者及机构间合作欠紧密。老年口腔健康研究的热点是老年护理、口腔健康以及老年人的生活质量。结论 老年口腔疾患随着年龄的增长而增多,对其生活质量造成直接影响。关注老年人的营养和口腔卫生,探索并制定有针对性的个性化干预策略,有助于改善老年人的口腔卫生状况,呵护身心健康,提高生活质量。     

Organizing an academic nursing home. Impacts on institutionalized elderly

In March 1984, a program for an academic nursing home was established at the Sepulveda Veterans Administration Medical Center. The program was designed to improve care of nursing home patients, provide interdisciplinary training for medical house staff and allied health students, and stimulate research. Geriatric faculty physicians were appointed, medical house staff were assigned as primary physicians to groups of patients, and geriatric nurse practitioners were hired to provide day-to-day care. A two-phase evaluation of the impact of the academic nursing home on patient care was conducted. Beneficial developments associated with the program in concurrent comparison with the standard nursing home unit included a significant decrease in patient transfers to the acute-care hospital and significant improvements in functional status, patient satisfaction, and morale. A trend toward improved survival was nonsignificant. Longer-term follow-up revealed a significantly increased rate of discharge for patients completing long-term rehabilitation. Overall, the costs of nursing home care were only minimally increased by the program. Results suggest that programs like the academic nursing home can lead to improved process and outcomes of nursing home care.     

Effect of a geriatric consultation service on management of patients in an acute care hospital.

Elderly patients present particular management challenges. We conducted a randomized clinical trial of the effect of a geriatric consultation service on the management of elderly patients in an acute care hospital. A total of 113 patients aged 75 years or more who met certain criteria were assigned to either receive (57 patients) or not receive (56) care by the service. At the end of their hospital stay the patients were assessed with regard to predetermined outcomes. The patients were followed up for 1 year after discharge to determine death rates and direct health care expenditures. The intervention group showed significantly greater improvement in mental status (p less than 0.01), were receiving fewer medications at discharge (p less than 0.05) and had lower short-term death rates (p less than 0.05) than the control group. A geriatric consultation service can improve the hospital care and health of the elderly.     

Medical home care services for the housebound elderly.

In our health jurisdiction the proportion of elderly people is more than double the national average, and there is a severe shortage of both home care services and long-term care beds. To help the many elderly housebound people without primary medical care we initiated a medical services home care program. The goals were patient identification, clinical assessment, medical and social stabilization, matching of the housebound patient with a nearby family physician willing and able to provide home care and provision of a backup service to the physician for consultation and help in arranging admission to hospital if necessary. In the program's first 2 years 105 patients were enrolled; the average age was 78.9 years. More than 50% were widowed, single, separated or divorced, over 25% lived alone, and more than 40% had no children living in the city. In almost one-third of the cases there had never been a primary care physician, and in another third the physician refused to do home visits. Before becoming housebound 15% had been seeing only specialists. Each patient had an average of 3.2 active medical problems and was functionally quite dependent. Thirty-five of the patients were surveyed after 1 year: 24 (69%) were still at home, and only 1 (3%) was in a long-term care institution; 83% were satisfied with the care provided, and 79% felt secure that their health needs were being met. One-third of the patients or their families said that it was not easy to reach the physician when necessary. We recommend that programs similar to ours be set up in health jurisdictions with a high proportion of elderly people. To recruit and retain cooperative physicians hospital geriatric services must be willing to provide educational, consultative and administrative support.     

Care for Canada''s frail elderly population: Fragmentation or integration?

Budget constraints, technological advances and a growing elderly population have resulted in major reforms in health care systems across Canada. This has led to fewer and smaller acute care hospitals and increasing pressure on the primary care and continuing care networks. The present system of care for the frail elderly, who are particularly vulnerable, is characterized by fragmentation of services, negative incentives and the absence of accountability. This is turn leads to the inappropriate and costly use of health and social services, particularly in acute care hospitals and long-term care institutions. Canada needs to develop a publicly managed community-based system of primary care to provide integrated care for the frail elderly. The authors describe such a model, which would have clinical and financial responsibility for the full range of health and social services required by this population. This model would represent a major challenge and change for the existing system. Demonstration projects are needed to evaluate its cost-effectiveness and address issues raised by its introduction.     

Consultative geriatric assessment for ambulatory patients. A randomized trial in a health maintenance organization

Previous studies have shown that comprehensive geriatric assessment and follow-up can improve the health of hospitalized elderly patients. To evaluate the effectiveness of consultative geriatric assessment and limited follow-up for ambulatory patients, we randomized 600 elderly patients who were enrolled in a health maintenance organization into three groups: (1) consultation by a geriatric assessment team, (2) consultation by a "second opinion" internist, and (3) only traditional health maintenance organization services (control patients). The geriatric assessment team identified previously unrecognized problems in 35% of patients and advised changes in medication regimens for more than 40%. Nevertheless, patients who received assessment achieved only a small benefit in cognitive function after 3 months, which was not sustained for 1 year. There was no difference among groups in other measures of health status. Consultative geriatric assessment with limited follow-up did not benefit most older ambulatory patients in a health maintenance organization; if such care can be used effectively for ambulatory patients, it will require either additional targeting or continuing care or both.     

美国老年医学教育对我国老年医学教育的启示

面对人口老龄化的趋势,发展现代老年医学和教育在我国势在必行。美国老年医学和教育相对完善,通过对美国老年医学和教育的发展现况简要介绍,如老年病房、老年髋部骨折专诊、亚急性和过渡性医疗、全面的老年人服务项目、退休养老社区实施老年医疗,以及老年医学教育课程设置、研究生培养方法、老年病医师资质证明等,分析其特点和优势,探讨对于我国老年医学、老年医疗保健和老年医学教育的启示,为促进我国老年医学和老年医学教育的发展提供借鉴。     

老年医学的核心技术——老年综合评估

老年综合评估是老年医学的核心技术,正确掌握和合理应用其技术与方法,对老年病急性期的诊治、急性后期和亚急性期的中期照护、长期照料、临终关怀与社区慢病防控等都具有重要的指导作用和临床应用价值。老年综合评估是现代医学模式在老年医学中的具体应用,它不仅包括一般的医学评估（诊断）,而且还包括对老年人躯体功能、精神心理、社会经济、生活环境和生存质量等方面的评估,尤其在常见老年综合征和老年问题的评估中得到了广泛的应用。通过老年综合评估,可为老年患者制定科学、合理和有效的预防、保健、治疗、康复和护理计划,促进老年患者各种功能状态的改善,从而提高老年患者的生命质量和健康期望寿命。     

国外老年开业护士的培养现状概述

随着我国人口老龄化进程的加速,老年医疗保健需求增加,对老年护理人才的培养提出了更高的要求。我国尚无老年开业护士的培养体系,故本文对国外老年开业护士硕士和博士研究生培养项目的学制,课程内容,培养目的,实践的时长、地点及主要内容,教学方法的种类及开展形式,课程测评和毕业考核的内容及要求等方面展开介绍,以期为国内老年开业护士培养提供参考。     

医养结合视角下对基层社区卫生服务机构举办养老机构模式的探索与研究——基于北京市西城区月坛社区卫生服务中心举办银龄老年公寓的案例分析

随着我国人口老龄化进程逐年加快,养老问题日益突显。2013—2021年,国务院办公厅陆续发布了关于推进医养结合服务、提升养老服务质量、加强新时代老龄工作等若干意见。由此,基层医疗卫生机构与养老机构将“老有所医、老有所养”如何合作与分工等问题摆上重要议事日程。本文从基层社区卫生服务机构举办养老机构这一模式的重要性和必要性出发,从“服务主体、服务内容、服务形式、服务对象、运行效果”5个维度分析其存在的优势及面临的困境,期望可以逐步实施医养结合能力提升行动、建设高质量的社区医养结合模式、推广健康老龄化理念。     

The home as a site for teaching gerontology and chronic illness

The care for the chronically ill elderly is a major national health problem. Considerable concern and attention have been focused on the shortcomings of medical education in this area of care. Research findings have demonstrated the relevance of a home care experience for teaching the interactions of the social, psychological, environmental, and biological factors which characterize chronic illness. The value of such an experience has taken on added significance in light of the federal government's prospective payment system for reimbursing health care costs under the Medicare program, a system that encourages early discharge of patients from the hospital. To manage these patients successfully, physicians need to understand and appreciate the influence of social, psychological, and environmental factors in the course of a disease. The home setting is an appropriate place for teaching about these factors, just as the hospital ward is appropriate for the understanding required of acute illness.     

Old age and new policy

In light of the projection of increasing deficits in the present Medicare program, we must rethink our goals for health in old age and curb our insatiable appetite for longer life regardless of expense. The failure of efforts to control costs through efficiency measures has forced elderly persons to forgo decent long-term or home care, and yet public opinion continues to expect more and better health care with no corresponding inclination to pay for it. The emphasis of entitlement programs must be shifted from short-term, critical care medicine for the elderly to the provision of care that improves the quality of their day-to-day life, while not necessarily extending that life; the most expensive forms of life-extending care would then be rationed according to a flat age limitation decided upon collectively by society.     

A geriatric day hospital: the Sunnybrook experience.

A review of the first 7 years of experience with the geriatric day hospital at Sunnybrook Medical Centre in Toronto revealed the following about the patients attending the day hospital during that time: most were 60 to 79 years old; over 85% attended 1 or 2 days a week; more than two thirds lived with a spouse or relatives; and more than half had diseases of the circulatory system or mental disorders. The day hospital offers a varied therapeutic program while easing the demands on the energy and time of the patient's spouse or family and thus helps the elderly to remain in the community rather than live in an institution. The experience at Sunnybrook has shown that geriatric day hospitals can be a valuable component of the broad spectrum of integrated services and programs that must be developed to provide adequate health care for the growing number of older people in our population.     

Cost-effectiveness of primary tetanus vaccination among elderly Canadians.

Although tetanus is now rare, vaccination is currently recommended for the entire population. Most elderly North Americans have never received tetanus vaccination. We evaluated the expected cost-effectiveness of using mailed reminders from family physicians to increase primary tetanus vaccination coverage among elderly Canadians. We estimated that over 10 years the program would prevent five cases of tetanus and one death from tetanus, resulting in a gain of 13 life-years. There would be 16,700 adverse reactions to tetanus toxoid, 17% in people already immune to tetanus. The net cost of the program (in 1984 Canadian dollars) would be $1.9 million per case of tetanus prevented, $7.1 million per death prevented and $810,000 per life-year gained. These high cost-effectiveness ratios are largely attributable to the very low risk of tetanus, even among nonimmune elderly people. Tetanus toxoid and physicians' services for vaccination would account for 86% of the program costs. Because the mailed reminders would be responsible for only 13% of the program costs, other possible programs to increase primary tetanus vaccination coverage could not be expected to have substantially lower cost-effectiveness ratios. We conclude that efforts to increase primary tetanus vaccination coverage among elderly Canadians would be a questionable use of health care resources.     

老年综合评估在老年衰弱群体中的应用现状及思考

随着中国进入老龄化社会，老年人口急剧攀升，由此造成养老成本持续增加，养老照护负担持续加重。衰弱是老年群体失去自理能力、产生养老问题的重要原因，其不仅意味着生理功能的下降，还与心理、社会经济等多领域能力衰退相关，被认为是影响老年人生活质量的重要老年综合征。老年综合评估（CGA）是专门针对老年患者的多层面、多学科的评估干预过程或模式，作为老年医学的核心技术，其采用多维度、多学科综合的方法评估老年人的躯体情况、功能状态、心理健康和社会环境状况等，并据此制定治疗计划以维持和改善老年人功能状态，最大限度提高老年人的生活质量，然而国内外对CGA的应用并不完全一致。由此，本文回顾了现有的国内外文献，探讨目前老年衰弱现状，分析CGA技术在老年衰弱患者中应用的优势与不足，发现国内外对于衰弱患者的干预逐渐重视，国内对于衰弱的干预研究处于起步状态，多以随机对照试验为主，且多应用于住院慢性病患者，国外对于衰弱的干预性研究开展较为广泛，研究者除了将CGA技术应用于慢性病衰弱患者及社区衰弱老年人，还应用于肿瘤患者及围术期患者。CGA技术的优势在于可以全面评估老年人的衰弱情况，并基于此进行干预以延缓或阻止老年衰弱的...     

Evolution of an active psychogeriatric day hospital.

A geriatric day hospital was established as part of the psychogeriatric unit of the Royal Ottawa Hospital. While initially this day hospital was integrated with day hospital programs of other units, it became apparent that a separate facility was desirable. The activities and programs of the psychogeriatric day hospital, run by one registered nurse, were integrated with those of the geriatric inpatient unit. It was found to be advantageous for inpatients and day hospital patients to share the same physical facilities. The majority of day hospital patients came from the inpatient unit; almost all had affective disorders. The emphasis was on reintegration into the community. During the 1st year of operation there were 75 patients in the program; only 3 needed admission to the inpatient unit and 1 was readmitted after discharge.     

积极探索老年健康服务方略

随着社会经济的发展,人口发展出现＂三低一高＂现象。老龄服务事业和产业已成为国家战略,针对目前老年健康发展现状,我校开始致力于以下3个方面的探索：围绕老年健康服务打造办学特色;建立＂全国老年医学与照护人才培训中心＂,构建老年医学与老年照护人才培养体系;成功申报＂四川养老与老年健康协同创新中心＂,积极探索老年健康服务方略。