哥本哈根市康复工作

哥本哈根市康复工作ResponsibilityforhealthinDenmark

丹麦医疗卫生职责划分TheState/Nationallevel国家层面MinistryofHealthandNationalBoardofHealth卫生部和国家卫生委员会Regulation,legislation,qualitystandardizations政策法规制定，质量标准Regionallevel-TheCapitalRegion:大区级别–首都大区Hospitalservice–somaticandpsychiatric医院服务–身体和精神Generalpractitioners,medicalspecialistsetc.全科医生，医疗专家等Municipalitylevel-CityofCopenhagen,市级别-哥本哈根市TheHealthandCareAdministration:卫生保健部Healthpromotionanddiseasepreventionforallcitizens

全体民众的健康促进和疾病预防Rehabilitationprogramsafterdischargefromhospital (chronicdisease,muscularrehabilitation)出院后的康复项目（慢性疾病，肌肉康复）Elderlycareforcitizensage65andup–servicesandactivities年龄在65及以上民众的养老服务–服务和活动Rehabilitationwithouthospitalization无需住院的康复工作AfewfactsaboutCopenhagen哥本哈根部分数据Municipality:580.292people(Denmarktotal:5,7mill.)Area:89km2市：580.292人(丹麦共5.700.000人）地域：89平方公里GreaterCityarea:1,2mill.CapitalRegion:2mill.People城市大区：1.200.000,哥本哈根大区:2百万Lifeexpectancyforwomen:80years女性寿命:80岁Lifeexpectancyformen:74,7years男性寿命：74.7岁Strongpopulationgrowth:强势人口增长1000newcitizenseverymonth每月1000新市民In2025,therewillbe670,000

Copenhageners;anincreaseof33%

over20years.截止2025年，将达到670,000人，20年中33%的增长Thisisduetoahighnumberofyoung

incomers,ahighratioofbirthstodeaths

andimmigration.由于年轻人数量多，高出生死亡率以及移民Therapistsemployed:330雇佣的治疗专家330名TheMunicipalityofCopenhagen哥本哈根市CopenhagenCityCouncil哥本哈根市政委员会AuditDirectorateCopenhagen

哥本哈根审计总局CitizensAdviceService

公民咨询服务TheFinance

Committee金融委员会TheCultureandLeisureCommittee

文化休闲委员会TheEmployment

andIntegration

Committee就业和一体化委员会TheTechnicaland

Environmental

Committee

技术和环境委员会TheChildrenand

YouthCommittee

儿童青少年委员会TheHealthand

CareCommittee

卫生保健委员会TheSocial

Services

Committee

社会服务委员会Chairman主席MayorCarlChristianEbbesenChairman主席LordMayorFrankJensenChairman主席MayorAnnaMee

AllerslevChairman主席MayorMortenKabellChairman主席

MayorJesperChristensenChairman主席MayorNinnaThomsenChairman主席MayorPiaAllerslevAdministrationAdministrationAdministration行政管理Administration行政管理Administration行政管理Administration

行政管理Administration行政管理Administration行政管理Administration行政管理4

TheHealthandCareAdministration卫生和保健部

Maintasksandservices:主要任务和服务Rehabilitationafterdischargefromhospital出院后康复Rehabilitationafterfunctionaldeclineintheelderly老年人身体功能下降后的康复Rehabilitationofcitizenswithachronicdisease慢性病患者的康复Elderlycare:Includinghomecare,assistivedevices,residentialnursinghomes,rehabilitation,activityoffers,dentalcare,nursing,foodservice养老服务：包含家庭护理、辅助器械、居住性疗养院、康复服务、活动提议、牙科护理、护理服务、食品服务Healthpromotionanddiseasepreventionforallcitizens全体民众的健康促进和疾病预防

Healthcarechallengestothemunicipalities

市府的医疗卫生挑战Demography人口统计方面Moreelderlypeoplewithlongtermconditions.越来越多长期病患的老年人In204025%ofthepopulationwillbemorethan65yearsofage(today19%)在2040年，25%的人口将超过65岁（目前为19%）Increaseinchronicdisease慢性疾病增加Increasednumberofcancersurvivors癌症病患幸存者增加Resources资源方面Fewerpeopleintheworkforce–givingasmallertax-baseleadingtoabudgetsqueeze劳动力越来越少–纳税少，预算紧Expectations期望值方面Highexpectationstolifeasseniorcitizens老年人对生活的高期望Inequality不平等性SocialInequalityinthedistributionofhealth

卫生资源分布方面的社会不平等性ShorterHospitalizationtime缩短的住院时间fromapprox9daysto4.5days(goingto2.5days)从大约9天到4.5天（将降到2.5天）TheNationallevel国家层面

2007TheLocalGovernmentReformandHealthLegislation2007年地方政府改革和卫生立法Fundamentalreformationofthemunicipalities(from271to98)市级的巨大变革（从271个市到98个市）Everycitizenentitledtorehabilitationfreeofchargeintheirmunicipality,providedtheyhavearehabilitationplanfromthehospital只要市民有从医院得到的康复计划，他们就可享有免费康复服务Rehabilitationbecametheresponsibilityofthemunicipalities康复服务成为市级政府的责任20082008年Municipalitiestakeoverresponsibilityforphysiotherapyfreeofchargeforcitizens(morediagnoses)市级政府接过为市民提供免费理疗的职责（更多的诊断）20152015年NewlegislationonrehabilitationinthemunicipalitiesandthehospitalsectorIntroducingabasicandadvancedlevelofrehabilitation.对市级和医院中康复的新立法，带来基本且提升的康复服务Newlegislationonrehabilitationinhomecare.对家庭护理康复的新立法Focusonthequalityofrehabilitation重视康复服务质量

TheRegionallevel大区级别

DoctorsinthehospitalprescribesanRehabilitationplan医院里的医生指定康复计划healthcareagreementsbetweenmunicipalities

andRegion–includingGP市府和大区间的卫生协议–包含全科医生Healthtasksonregionallevelandmunicipalitylevel

大区级别和市级别的卫生任务Thereisaneedforco-ordinationand

cooperationbetweenprimaryand

secondarycare基础医护和二级医护间需要协调和合作

GP全科医生Municipality市政府Hospital医院TheMunicipalLevel市级层面

TheHealthandElderlyPoliciesofCopenhagen

哥本哈根市卫生和养老政策HealthPolicy2015-25卫生政策2015-25CopenhagenElderlyPolicy2015-2018哥本哈根市养老政策2015–2018Rehabilitation(theDanishdefinition)

康复（丹麦的定义)Thedefinitionisasfollows:定义如下Rehabilitation:Agoal-oriented,cooperativeprocessinvolvingacitizen,his/herrelatives,andprofessionalsoveracertainperiodoftime.Theaimofthisprocessistoensurethatthepersoninquestion,whohas,orisatriskofhaving,seriouslydiminishedphysical,mentalandsocialfunctions,canachieveindependenceandameaningfullife.Rehabilitationtakesaccountoftheperson'ssituationasawholeandthedecisionsheorshemustmake,andcomprisescoordinated,coherent,andknowledgebasedservices.康复：在特定时期以目标为导向通力合作的过程，这一过程涉及公民本人、他（她）的家属以及专业人员。这一过程的目的是要确保病患，不论他的身体、精神和社会功能已经严重缩水或有这方面的风险，都能够实现独立和有意义的生活。康复需要考虑到病患的整体情况以及他（她）所必须做出的决定，并且需要包含协调、一致和基于知识层面的服务。Rehabilitationmindsetinelderlycare.

老年护理的康复观念模式Settingupgoalsincollaborationwiththeoldperson与老年人建立合作目标Aimingatindependencyandself-help以独立和自立为目标Involvementoftherelatives亲属参与Evidencebased循证Multiprofessionalismworkinginteams团队多元化专业合作Userinvolvementindecisions用户参与决策Rehabilitationofbothphysical,mentalandsocialfunctions身体、精神和社会功能的康复Genericprocessinrehabilitation

康复的一般过程FunctionalDeclineoftheelderly老年人功能性衰弱

Potential潜能Motivation激励Involvingrelativesifrelevant包括相关的亲属Ongoingfollow-upwiththecitizen.MeasuringeffectusingPSFS对公民持续跟踪

通过PSFS衡量效果Theimpactafterthreemonths(PSFS)三个月后的效果(PSFS)Settingupgoalsandplanningtheprocesswiththecitizen与公民制定目标并且规划过程Hospital医院Neuro-rehabilitering神经康复In-patientRehabilitering住院患者康复In-patientRehabiliteringCenterWelfaretechnology住院患者康复中心福利技术DementiaCenter老年痴呆症中心Home家庭Nursinghome护理院Acutein-patientnursingcarecenterandPalliativeCenter急性住院患者护理中心和姑息治疗中心GP全科医生Shared-careunit共享监护病房Rehabilitation康复Cohesiveandco-ordinatedpatientpathwayacrosssectors跨部门凝聚和协调病人的途径HealthCenter健康中心Dischargecoordi-nators出院协调Home家庭09-04-202313QualitymanagementintheHealthandCareadministrationofCopenhagen

哥本哈根市卫生保健管理中的质量管理

Qualityorganization质量组织Monitoringthreedimensionsofquality监控三方面质量问题Thequalityasperceivedbythecitizen市民角度的质量问题Theprofessionalquality专业质量问题Theorganizationalquality组织质量问题Makesuseof利用Usersurveys用户调查Auditing审计Qualitycircleindevelopmentprojects开发项目质量Inspection检验Nationalstrategiesfordigitalizationinthehealthsector.

国家健康部门数字化战略

DigitalWelfare2013-2020:NationalplanforDigitalsupportanddigitalsolutionstowelfareservices.数字福利规划2013-2020:国家数字支持和解决方案福利规划Timetochangeintolessco-presenceofcitizenandhealthprofessional转变至与健康专家更少相处DigitalsupporttorehabilitationWhy

为什么使用数字支持进行康复治疗？

Changes改变Empoweringthecitizen.Rehabilitationinfocus.授权于公民，专注于康复治疗Makingtrainingavailabletothecitizen.Nomoretravellingpatients.向公民提供培训，减少患者出行Adherencetotherehabilitation:homeexercise,maintenanceofthetrainingeffort坚持康复治疗：家庭锻炼、坚持培训Whenreducingthenumberofhospitalbeds1/3and25%ofthepopulationmorethan30kmtonearesthospital(today14%).Weneednewsolutions需要新的解决方案能将医院病床数量减少1/3，并将距离最近医院30公里的患者人群上升到25%左右（如今是14%）Challenges挑战Demography,moreelderly更多老年人口20%increaseinrehabilitationplansfromhospitals医院康复治疗方案数量将增加20%Digitalizationiscentralinthenationalstrategies数字化是国家战略的核心Gainrealizationfrom2017自2017年起开始实施Digitalsupporttorehabilitation.Stationarysensorsandpersonheldsensors

康复数字支持：固定传感器和手持传感器

VirtuelGenoptræning®DigiCorpus®ICURA®3Gtelephoneconnection3G电话连接Individualizedtrainingprograms个人培训项目Deliveringvideo,auralinstructioninexercises提供视频和听力指导训练Feedback,smileyandpercentachieved.得到热情的反馈Accesstothetrainingdatahostedontheserverofthemanufacturer.访问制造商服务器上的培训数据PTcanaltertrainingattheadministrationsite理疗师可以在管理网站更改训练项目Targetgroup目标群体Frailelderlyinriskofadmission/readmission有住院和再住院风险的年老体弱者Elderlywithouttheenergytogototherehabilitationcentres.疲于前往康复中心的老年人Continuoustrainingbetweeninpatienttrainingandoutpatienttraining有持续住院和门诊培训需求的人群Youngerpeopleactiveo