(中德康复技术培训课件)2506 Gutenbrunner 中徳康复合作领域

Systematicapproachtoimplementrehabilitationinhealthsystems–collaborationbetweenChinaandGermany完成健康体系中的康复医学的系统化处理方法-中德合作

ChristophGutenbrunnerChristophGutenbrunner,MD,PhD,ProfessorDepartmentforRehabilitationMedicineCoordinationCentreforRehabilitationResearchHanoverMedicalSchoolD-30625Hannovergutenbrunner.christoph@mh-hannover.deSystematicapproachtoimplemeOverview内容概要•Arguments:whyshouldweworkontheimplementationof rehabilitationservices?论证：为什么我们应当致力于康复服务的实行？•Conceptualapproach:howtoanalyse,plananimplement rehabilitationservices概念性的探讨：如何分析，计划康复服务的实行•Challengesandopportunities: 挑战与机遇

◦Whatarethechallengesofplanningandimplementation projects?计划和和实行方案会有着怎样的挑战◦Whataretheopportunitiesofcollaboration?相互合作会带来什么样的机遇Overview内容概要•Arguments:whyArguments:whyshouldweworkontheimplementationof rehabilitationservices?论证：为什么我们应当致力于康复服务的实行？Arguments:whyshouldwework•TheInternationalClassificationofFunctioning,DisabilityandHealth (2001)国际健康功能与身心障碍分类系统•UN-ConventionfortheRightsofPeoplewithDisabilities(2006)联合国残疾人权利公约•WorldReportonDisability(2011)

世界残疾报告•The“InternationalPerspectivesofSpinalCordInjury”Report(2013)脊髓损伤国际展望报告•ResolutionWHA66.9„Disability“(2013)世界卫生大会66.9号残疾决议•TheWHOGlobalDisabilityActionPlan„BetterHealthforallpeople withdisabilities2014-2021“(2014)世卫组织2014–2021年全球残疾问题行动计划：增进所有残疾人的健康Theinternational“normative”approach国际”标准化“•TheInternationalClassificaTheUN-CRPD

(2006)联合国残疾人权力公约•Article26:HabilitationandRehabilitation ◦StatesPartiesshalltakeeffectiveandappropriate measures,includingthroughpeersupport,toenable personswithdisabilitiestoattainandmaintain maximumindependence,fullphysical,mental,social andvocationalability,andfullinclusionand participationinallaspectsoflife.Tothatend,States Partiesshallorganize,strengthenandextend comprehensivehabilitationandrehabilitation servicesandprogrammes,particularlyintheareas ofhealth,employment,educationandsocial 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、教育和社会服务方面TheUN-CRPD(2006)联合国残疾人权力公约•ActionPlan:objectives行动计划：三大目标(1)

toremovebarriersandimproveaccesstohealthservicesand programmes1)清除障碍并提高卫生服务和规划的可及性(2)

tostrengthenandextendrehabilitation,habilitation,assistive technology,assistanceandsupportservices,andcommunity- basedrehabilitation(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)tostrengthencollectionofrelevantandinternationallycomparabledataondisabilityandsupportresearchondisabilityand

relatedservices

(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ActionPlan:objectives行动计划：三大TheWHOGlobalDisabilityActionPlan

(2014)世卫组织全球残疾问题行动计划•Objective2:tostrengthenandextendrehabilitation,habilitation, assistivetechnology,assistanceandsupportservices,and community-basedrehabilitation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 ◦Action2.4:Expandandstrengthenrehabilitationand habilitationservicesensuringintegration,acrossthe continuumofcare,intoprimary(including community),secondaryandtertiarylevelsofthe healthcaresystem,andequitableaccess,including timelyearlyinterventionservicesforchildrenwith disabilities2．4扩大并加强康复和适应训练服务，确保与持续照护一起纳人初级(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TheWHOGlobalDisabilityActiTheWHOGlobalDisabilityActionPlan

(2014)•ProposedinputsforMemberStates: ◦Reviewexistingrehabilitationandhabilitationprogrammes andservicesandmakenecessarychangesto improvecoverage,effectivenessandefficiency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•ProposedinputsfortheSecretariat: ◦Supportcountriesinintegratingrehabilitationandhabilitation servicesintothehealthsystem(…) ◦Developrelevanttoolsandtrainingpackagestodevelop andstrengthenhabilitationandrehabilitationservices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•Proposedinputsforinternationalandnationalpartners: ◦Workwithhealthministriestoexpandandstrengthenthe provisionofrehabilitationandhabilitationservices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TheWHOGlobalDisabilityActiHealthaccountsvs.strategiesNoDimensionsofICHA-HCHealthCareStrategies(Stuckietal.)卫生保健策略1HC.1:Servicesofcurativecare根治性治疗服务Curativecare(curativestrategy)根治治疗(根治性策略）2HC.2:Servicesofrehabilitativecare康复治疗服务Rehebilitativecare(rehabilitativestrategy)康复治疗（康复性策略）3HC.3:Servicesoflong-termnursingcare长期护理服务Maintenancecare(supportivestrategy)保养治疗（支持性策略）4HC.4:Ancillaryservicestohealthcare卫生保健的附属服务5HC.5:Medicalgoodsdispensedtoout-patients门诊病人的医疗用品发放6HC.6:Preventionandpublichealthservices预防与公共卫生服务Prevention(preventivestrategy)预防（预防性策略）7HC.7:Healthadministrationandhealthinsurance卫生行政与健康保险Healthaccountsvs.strategiesIn-patientordayclinicrehabilitationforpatientswithchronicconditionsLevelstodescriberehabilitation康复的各描述水平Macrolevel宏观水平Mesolevel中间水平Microlevel微观水平Healthstrategy,policy健康策略及政策Serviceprovision,concepts服务分配及慨念Healthcondition&functionallevel(B)Healthcondition&functionallevel(A)健康条件及功能水平（A)….In-patientordayclinicrehabTimeIntensity强度Acutecare急性治疗Post-acutecare急性期治疗Lon-termcare长期治疗Intermittentrehabilitation(in-patientorday-clinic)间断性康复（门诊或日间诊所）Post-acurterehabilitation(in-patient)急性期后康复（住院病人）Communitybasedrehabilitation(out-patient)以社区为基础的康复（门诊病人）Acuterehabilita-tion(inhospital)急性康复（院内）Integrativephasemodelofrehabcare康复治疗的整合分期模式GutenbrunnerC,MeyerT,StuckiG::AmJPhysMedRehabil2011;90:521-525TimeIntensity强度Acutecare急性治疗PLevel4:Multi-professionalrehabilitationservices水平4多专业性康复服务Level1:families,peers,etc.水平1：家庭，病友等等Level3:PRM,specializedPT,OTetc.水平3：康健医学，专业理疗师，职业治疗师等等Level2:primarycarephysicians,PT,OT,etc.水平2：初级护理医生，理疗师，职业治疗师等等Coordinatedreferralsystems(PRMasadvisorandcoordinator)←PRMdeliveredservicesPRMastrainer➔Level5:highlyspecializedrehabilitationservices(SCI,TBI)水平5高专业化的康复服务（脊髓创伤，脑创伤Levelsofspecialization康康复专业水平Level4:Multi-professionalCommunityBasedRehabilitation基于社区的康复GutenbrunnerC(2014):submittedCommunityBasedRehabilitationThehealthsystemsapproach卫生系统探讨•Rehabilitationcanbeseenasahealthstrategyitalsoisdescribed as“asetofmeasures” 康复可被视为健康战略也可描述成”一揽子计划”•Rehabilitationshouldbeintegratedinacute,post-acuteand long-termcare康复应被整合于急性期,急性期后及长期性治疗中•Rehabilitationshouldbeintegratedinprimary,secondaryandtertiary levelsofhealthcareservices康复应被整合于医疗服务的一级至三级水平中•Multi-professionalrehabilitationservicesneedhighstandardof serviceprovisionincludingresourcessuchasfacilities, technicalequipmentandhumanresources多专业性康复服务需要高标准的服务供给,包括设施,技术设备及人力资源Thehealthsystemsapproach卫生系Theindividualapproach(examples)病人个人探讨(举例)•Patientswithlongtermmechanicalventilationwilldevelop contractures,looseventilationcapacity,developmuscle atrophy,loosecirculatorycapacity,areinriskofpneumonia andthrombosisandothers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.•Patientsafterstrokewilllooseopportunitytoinduceneuroplasticityif rehabilitationdoesnotstartimmediatelyafterincident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•Patientswithmusculo-skeletalpainsyndromesareatriskdo developchronicgeneralisedpainsyndromesifprimary sourceofpainisnottreatedsufficiently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.•Patientswithchronichealthconditionsareatrisktobeunfitforwork ifrehabilitationislacking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•Lackofrehabilitationisahealthrisk,threattodevelopdisability缺失康复是一个健康风险,甚至可威胁发展至残疾Theindividualapproach(exampEconomic&developmentapproach

(arguments)经济与发展探讨(论证)•Lackofrehabilitationincreasecostsofhealthcareandsocial 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 ◦lengthofstayinICU‘saninhospitalwillbelongerICU时间将会增加 ◦outcomesofinterventions(e.g.surgery)willbepoorer ◦干预手段(如外科手术)的结果变差theprevalenceofdisabilitywillbehigher 致残发生率增加 ◦Contributionofindividualstosociety(andsocialproductivity) willbelower个人对社会(和社会生产力)的贡献减少•Lackofrehabilitationisaneconomicanddevelopmentalrisk,e.g. ◦disabilitywithoutrehabilitationisaburdenforhealthsystems ◦Lackofemployees(esp.ofhigheducation)harmsdevelopmentalprocesses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•Theprovisionofrehabilitationservicesmayalsobeabusiness康复服务的分配也可成为Economic&developmentapproacConceptualapproach:howtoanalyse,plananimplementrehabilitationservices

概念方法：如何分析，计划开展康复服务Conceptualapproach:howtoanStepwiseapproach(1)阶梯式方法⚫Step1:Agreementonbasicprinciples(e.g.UN-CRPD,WRD,WHA Resolution66.9,Disabilityactionplan)第一阶段达成基本共识⚫Step2:Analysisoftheburdenandmajorcausesofdisability:

第二阶段残障的主要原因及难点分析

◦Trafficaccidentsandothertrauma(incl.spinalcordinjury, traumaticbraininjury,multipletrauma)交通事故及其他外伤

◦Cardiovascularandmetabolicdiseases(incl.hypertension, myocardialinfarction,diabetes)心血管及代谢疾病

◦Neurologicalconditions(includingstroke,multiplesclerosis, Parkinson’sdisease)神经系统疾病

◦Chronicmusculoskeletalconditions(incl.LowBackpain, osteoarthritis,rheumatoidarthritis,chronicwidespreadpain andfibromyalgia)慢性运动系统疾病（肌肉骨骼）

◦Paedriatricconditions儿科疾病

◦Geriatricconditions(incl.frailty,dementia)老年病

Stepwiseapproach(1)阶梯式方法⚫Stepwiseapproach(2)阶梯式方法⚫Step3:Usemodelsofrehabilitationservices:第三阶段使用康复服务模型◦Implementrehabilitationalongthecontinuumofcare(acute,post-acute,

andlongtermrehabilitation)

沿用连续性护理实施康复治疗

◦Levelsofspecialization(fromacutecaretothecommunity) 专业化水平◦Multiprofessionalteamworkasprincipleofstaffing(PRM,PT,OT,SLT,

PsychotherapySocialworkandothers)多专业混合团队协作原则编制人员◦Definedinterfaces(incl.transfersystems)界定转诊标准

◦Createfinancialsystem(insurances,statesfinancingorothers)建立财务系统⚫Step4:Defineregions/areasandcalculateconcretedemandofservices

第四阶段定义区域并估算具体服务需求

⚫Step5:Machdemandwithprinciplesanddefineconcreteplan第五阶段：以服务需求为原则，并确定具体计划Stepwiseapproach(2)阶梯式方法⚫StLevel1aLevel1bLevel2aLevel2bRehabilitationpolicy康复政策HighlyspecializedcentreSpecializedcentreRehabcentreRehabcentreDoctorPTOTS<othersPeers,families,self-helpinggroupsandothersLevel3CasemanagementLevelsofcareprovision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Level1aLevel1bLevel2aLevelExample举例Example举例⚫Acuterehabilitationservices:inorcloseto(acute)hospitals急诊康复-院内或附近⚫Post-acuterehabilitationservices:stand-alonerehabilitationfacilities inclosecooperationwithhospitals(highlyspecializedandspecialized)

急诊后康复-独立康复机构-合作医院附近⚫Long-termrehabilitationservice:out-patientormobileservices长期康复-门诊或随诊⚫Servicesforintermittentrehabilitationinchronicconditions:in-patient orday-clinics慢性病不连贯康复服务-入院或日间诊疗⚫Vocationalrehabilitationservices:integratedinrehabilitationandvocationalservices

职业训练康复服务-康复与职业训练集成的服务⚫Linkstosocialsystem:munityandpeers

与社会系统连接-比如社区及同伴支持Definitionofservices定义服务⚫AcuterehabilitationserviceIn-patientordayclinicrehabilitationforpatientswithchronicconditionsFrameworkofRehabServices:dimensions

康复服务的构架—多维度⚫Serviceprovider:thecategoriestodescribetheproviderincludethe frameworkoftheinstitution(location,organisationetc.)the resources(humanandtechnicalresources)andsomeaspectsof serviceorganisationsuchasprofit-orientationandquality assuranceprograms.Themainquestionsbehindarewhereandin whichcontexttheserviceisdelivered

服务的提供者，最主要的背后问题是在何地，何背景下提供服务⚫Fundingoftheservice:thecategoriesoffundingdescribethemainsources ofincomeandrefundingofservices.Theyincludethebasic principlesofpaymentsuchasdiagnosis-relatedgroups,per-day paymentofotherformsofservicerefund.Thequestionbehindis whataretheprinciplesoffinancialresources

服务资金来源，背后的问题是融资资金来源问题⚫Servicedelivery:thecategoriesonservicedeliverycontainthemain strategyappliedtotheusers,aspectsofintensityanddurationof interventionandthewaytheserviceisorganised(e.g.team structure).Itfocusesonthequestionhowtheservicesare deliveredtotheuser服务提供，关注如何向患者提供服务In-patientordayclinicrehabExample举例Example举例Example:Floorplanrehabunit康复单元平面图Example:FloorplanrehabunitExample:rehabunit(foreground)康复单元（前景）Example:rehabunit(foregroundTimeIntensity强度Acutecare急诊期管护Post-acuteCare后急诊期管护Lon-termcare长期管护Intermittentrehabilitation(in-patientorday-clinic)Post-acuterehabilitation(in-patient)Communitybasedrehabilitation(out-patient)基于康复的社交Acuterehabilita-tion(inhospital)Prevention预防Healthyliving(integratedindailyliving)Intermittentintensiveprevention(in-patient)Integrativephasemodelofrehabcare

康复管护的综合阶段模型间歇强化预防急诊期康复后急诊期康复间歇性康复TimeIntensity强度AcutecarePost-TimeIntensity强度Acutecare急诊期管护Post-acuteCare后急诊期管护Lon-termcare

长期管护Intermittentrehabilitation(in-patientorday-clinic)Post-acuterehabilitation(in-patient)Communitybasedrehabilitation(out-patient)基于康复的社交Acuterehabilita-tion(inhospital)Prevention预防Healthyliving(integratedindailyliving)Integratedphasemodelofrehabilitationcare(agreedqualitystandards)协定质量标准Intermittentintensiveprevention(in-patient)Integrativephasemodelofrehabcare

康复管护的综合阶段模型间歇强化预防间歇性康复后急诊期康复急诊期康复TimeIntensity强度AcutecarePost-Possibleconcreteprojects可能的具体项目⚫Designarehabilitationsystemmodelinadefinedregion(project)

在特定区域内设计一套康复系统模型⚫

Createanacademyforrehabilitationpersonnel(German-ChineseRehabilitationAcademy)为康复从业人员建立“德-中康复学院”⚫Planandrealizerehabilitationserviceforspecificdemandsortarget

groups计划并实行针对特定需求及目标群体的康复服务

◦leadersandmanagers面向领导及管理者

◦factoriesorindustries面向工厂或工业街

◦childrenorelderlypeople面向儿童或高龄人群

◦specifichealthconditions面向特定健康状况者⚫

Planandrealizeacomprehensiverehabilitationserviceinadefinedarea(town,neighborhood)在特定区域内计划并实行一套完整的康复服务（城镇、社区）⚫Methods:useGermanmodelorintegratedifferentinternational modelsandtransformintoaChinesemodel方法：利用德国模式或综合不同国际模式，转化成中国特色模式Possibleconcreteprojects可能的Challengesandopportunities:

挑战与机遇

◦Whatarethechallengesof planningand implementationprojects?

计划中和实施中的项目有什么样的挑战？

◦Whataretheopportunitiesofcollaboration?

合作中的机遇是什么？Challengesandopportunities: Challenges挑战•Convinceauthorities

取得政府支持•Developrealisticplan改善现实计划•Allocatemoney(findinvestors)非配资金（找到投资者）•Set-upunits(e.g.inhospitaland/orasrehabilitationcentres)建立康复单位（如建立康复医院或建立康复中心）•Set-upprograms(pathwaysandguidelines)建立项目（途径和方针）•Train(orrecruit)workforce培训（或引进）从业人员•Runservice(leadership,qualitymanagement)运行服务（领导，质量管理）Challenges挑战•ConvinceauthOpportunities机遇Philosophy:developChinesemodelusingGermanstndards理念：发展德标中用模式•AddedvalueofChineseandGermanexpertise(andarguments)

在中德经验求同存异中增加价值•SynergieswithISPRM’sactivities(WHOcollaborationplan)利用ISPRM活动的协同效应（WHO合作计划）•Strongsupportfrominternationalorganisations(andChinesegovernment)来自国际组织及中国官方的强力支持•NetworkofcollaborationpartnersinGermany德国合作伙伴网络•AccesstoGermanstandards(andexperience)(evenifavailableinGermanlanguageonly),e.g.借鉴德方标准（及经验）（即使仅能使用德语交流）◦Rulesforacuterehabilitation 急性期康复规则

◦Pathwaysforpostacuterehabilitation 后急性期通道

◦Vocationalrehabilitationprograms专业的康复方案项目

◦andothers及其他•Availablenetwork(spiritofcollaborationandmutualunderstanding)行之有效的网络（合作及理解互信的精神）Opportunities机遇Philosophy:Networks网络•Germany: 德方

◦HannoverMedicalSchool汉诺威医学院

◦GermanPensioninsurance(withrehabunits)德国养老保险（含康复单元部分）◦GermanWorkersAccidentinsurance德国工人意外保险

◦ChinabridgeGermany•China: 中方

◦NanjingUniversity 南京大学

◦TonjiUniversityWuhan 华中科技大学同济医学院武汉

◦ChinabridgeChina•International: 国际

◦ISPRM(andotherNGO’swithrelationtoWHO)ISPRM（及其他WHO相关合作组织）Networks网络•Germany: 德方 Outlook展望⚫Rehabilitationshouldbeimplementedintoallphasesofhealthcare康复应当在健康管护的全阶段进行⚫Theimplementationofhigh-qualityrehabilitationprogramscanimprovefunctioningandqualityoflifeofpatientsaftercardio-surgery高质量康复项目的实施可以改进心脏外科手术后的生活质量及功能⚫Rehabilitationprogramsalsohavethepotentialtoreducecostsinhealthsystem康复项目同样具有在健康系统中节约资源的潜力⚫Itmakessensetocombinetherehabilitationstrategywithpreventiveprograms康复策略同预防项目相结合具有积极意义⚫Concepts,standardsandexpertiseexisttodesigngoodrehabilitationprogramsandservice概念、标准及专科决定了是否可以设计出好的康复项目⚫Morescientificresearchonoutcomesofrehabilitationisneeded,inparticularaftercardio-surgery更多关于康复的科研结果需求增加，特别在心血管术后Vision:developandimplementamodelofcomprehensiverehabilitationcareinonecityorneighbourhood洞见：在单一城市及周边发展并实施全面完善的康复管护模式Outlook展望⚫RehabilitationshChristophGutenbrunner,MD,PhD,ProfessorDepartmentforRehabilitationMedicineCoordinationCentreforRehabilitationResearchHanoverMedicalSchoolD-30625Hannovergutenbrunner.christoph@mh-hannover.deThankyouforyourattention!ChristophGutenbrunner,MD,PhLevel1aLevel1bLevel2aLevel2bRehabilitationpolicy康复政策HighlyspecializedcentreSpecializedcentreRehabcentreRehabcentreDoctorPTOTS<othersPeers,families,self-helpinggroupsandothersLevel3CasemanagementLevelsofcareprovision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Level1aLevel1bLevel2aLevelAcuteRehabUnit急诊/急性期康复单元Otherwardsofhospital院内其他科室病房Post-acuteRehabilitation(out-patient;day-clinic)后急诊康复-门诊及日间Out-patientRehabilitation门诊康复Post-acuteRehabilitation(in-patient)后急诊康复-病房IntensiveCareUnit集中管护单元AcuteRehabilitationTeamstakecareofpatients,themedicalfocusisonotherspecialisedcaremedicalfocusisonfunctionalrehabilitationExamplesofinterfaces对接举例

AcuteRehabUnitOtherwardsofEvidenceofrehabilitationinICUICU病房康复实例EvidenceofrehabilitationinClinicalfieldReviewer/1stauthorStudies(numbersofparticipants)MDTmoreeffective?lowbackpain–multidisciplinarybiopsychosocialinterventionGuzmanJ,200810RCTs(1964)Betterfunction&paincontrolCoronaryheartdiseasemultidisciplinarydiseasemanagementMcAlisterFA,200112(9803)Feweradmitted,bettercontrolofriskfactors.MIrecurrence&survivalunchangedChronicdisablinglungdisease.OutpatientmultidisciplinaryrehabilitationGriffithsTL,20001RCT(200)lowerhospital&homevisitratesbetterwalking&healthstatusHmunityMDTtreatmentversususualcareStewartS19991RCT(200)Feweradmitted,betterdiet&drugcompliance,survivalsameMultiplesclerosis–InpatientMDTKhanF,20088RCTs(747)betteractivityparticipation,impairmentunchangedbraininjury–communityMDTversusinformationonlyPowellJ,20021RCT(110)betterthaninformationaloneSevereTBI–MDTversusstandardhospitalcareSemylenJK19981quasi-randomCT(56)Betterclinicaloutcome&carerslessdistressedV.NeumannA.,C.Gutenbrunner&A.Delarque:PositionPaperonTeamWorkinPhysical&RehabilitationMedicineEvidenceofteam-integratedrehabilitation

综合团队康复实例ClinicalfieldReviewer/1stau

GerdesNetal.:DiePROTOS-Studie.Steinkopff2000Evidenceofrehabinchronicconditions慢性病康复实例

GerdesNetal.:DiePROTOS-SGutenbrunneretal.:PhysMedRehabKuror2001;12:272-283EvidenceofrehabinchronicconditionsGutenbrunneretal.:Evidence-28%-23%Evidenceofjoborientatedprevention面向工作者的预防实例DaysDaysonsick-list:otherdiagnosesDaysonsick-list:JobRehabdiagnosesTotalnumberofdaysonsick-listbeforeJobRehabafterJobRehab-28%-23%EvidenceofjoborientSystematicapproachtoimplementrehabilitationinhealthsystems–collaborationbetweenChinaandGermany完成健康体系中的康复医学的系统化处理方法-中德合作

ChristophGutenbrunnerChristophGutenbrunner,MD,PhD,ProfessorDepartmentforRehabilitationMedicineCoordinationCentreforRehabilitationResearchHanoverMedicalSchoolD-30625Hannovergutenbrunner.christoph@mh-hannover.deSystematicapproachtoimplemeOverview内容概要•Arguments:whyshouldweworkontheimplementationof rehabilitationservices?论证：为什么我们应当致力于康复服务的实行？•Conceptualapproach:howtoanalyse,plananimplement rehabilitationservices概念性的探讨：如何分析，计划康复服务的实行•Challengesandopportunities: 挑战与机遇

◦Whatarethechallengesofplanningandimplementation projects?计划和和实行方案会有着怎样的挑战◦Whataretheopportunitiesofcollaboration?相互合作会带来什么样的机遇Overview内容概要•Arguments:whyArguments:whyshouldweworkontheimplementationof rehabilitationservices?论证：为什么我们应当致力于康复服务的实行？Arguments:whyshouldwework•TheInternationalClassificationofFunctioning,DisabilityandHealth (2001)国际健康功能与身心障碍分类系统•UN-ConventionfortheRightsofPeoplewithDisabilities(2006)联合国残疾人权利公约•WorldReportonDisability(2011)

世界残疾报告•The“InternationalPerspectivesofSpinalCordInjury”Report(2013)脊髓损伤国际展望报告•ResolutionWHA66.9„Disability“(2013)世界卫生大会66.9号残疾决议•TheWHOGlobalDisabilityActionPlan„BetterHealthforallpeople withdisabilities2014-2021“(2014)世卫组织2014–2021年全球残疾问题行动计划：增进所有残疾人的健康Theinternational“normative”approach国际”标准化“•TheInternationalClassificaTheUN-CRPD

(2006)联合国残疾人权力公约•Article26:HabilitationandRehabilitation ◦StatesPartiesshalltakeeffectiveandappropriate measures,includingthroughpeersupport,toenable personswithdisabilitiestoattainandmaintain maximumindependence,fullphysical,mental,social andvocationalability,andfullinclusionand participationinallaspectsoflife.Tothatend,States Partiesshallorganize,strengthenandextend comprehensivehabilitationandrehabilitation servicesandprogrammes,particularlyintheareas ofhealth,employment,educationandsocial 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、教育和社会服务方面TheUN-CRPD(2006)联合国残疾人权力公约•ActionPlan:objectives行动计划：三大目标(1)

toremovebarriersandimproveaccesstohealthservicesand programmes1)清除障碍并提高卫生服务和规划的可及性(2)

tostrengthenandextendrehabilitation,habilitation,assistive technology,assistanceandsupportservices,andcommunity- basedrehabilitation(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)tostrengthencollectionofrelevantandinternationallycomparabledataondisabilityandsupportresearchondisabilityand

relatedservices

(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ActionPlan:objectives行动计划：三大TheWHOGlobalDisabilityActionPlan

(2014)世卫组织全球残疾问题行动计划•Objective2:tostrengthenandextendrehabilitation,habilitation, assistivetechnology,assistanceandsupportservices,and community-basedrehabilitation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 ◦Action2.4:Expandandstrengthenrehabilitationand habilitationservicesensuringintegration,acrossthe continuumofcare,intoprimary(including community),secondaryandtertiarylevelsofthe healthcaresystem,andequitableaccess,including timelyearlyinterventionservicesforchildrenwith disabilities2．4扩大并加强康复和适应训练服务，确保与持续照护一起纳人初级(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TheWHOGlobalDisabilityActiTheWHOGlobalDisabilityActionPlan

(2014)•ProposedinputsforMemberStates: ◦Reviewexistingrehabilitationandhabilitationprogrammes andservicesandmakenecessarychangesto improvecoverage,effectivenessandefficiency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•ProposedinputsfortheSecretariat: ◦Supportcountriesinintegratingrehabilitationandhabilitation servicesintothehealthsystem(…) ◦Developrelevanttoolsandtrainingpackagestodevelop andstrengthenhabilitationandrehabilitationservices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•Proposedinputsforinternationalandnationalpartners: ◦Workwithhealthministriestoexpandandstrengthenthe provisionofrehabilitationandhabilitationservices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TheWHOGlobalDisabilityActiHealthaccountsvs.strategiesNoDimensionsofICHA-HCHealthCareStrategies(Stuckietal.)卫生保健策略1HC.1:Servicesofcurativecare根治性治疗服务Curativecare(curativestrategy)根治治疗(根治性策略）2HC.2:Servicesofrehabilitativecare康复治疗服务Rehebilitativecare(rehabilitativestrategy)康复治疗（康复性策略）3HC.3:Servicesoflong-termnursingcare长期护理服务Maintenancecare(supportivestrategy)保养治疗（支持性策略）4HC.4:Ancillaryservicestohealthcare卫生保健的附属服务5HC.5:Medicalgoodsdispensedtoout-patients门诊病人的医疗用品发放6HC.6:Preventionandpublichealthservices预防与公共卫生服务Prevention(preventivestrategy)预防（预防性策略）7HC.7:Healthadministrationandhealthinsurance卫生行政与健康保险Healthaccountsvs.strategiesIn-patientordayclinicrehabilitationforpatientswithchronicconditionsLevelstodescriberehabilitation康复的各描述水平Macrolevel宏观水平Mesolevel中间水平Microlevel微观水平Healthstrategy,policy健康策略及政策Ser