护理学报 ›› 2022, Vol. 29 ›› Issue (24): 27-31.doi: 10.16460/j.issn1008-9969.2022.24.027
田雨同, 张艳, 许冰, 鹿艺馨, 高梦珂, 李晓华, 高月, 刘莉, 赵婷
摘要: 目的 全面综述国外针对老年人的智慧整合照护模式,以期为完善我国养老服务体系提供参考依据。方法 系统检索国外文献及项目注册网站,总结归纳国外老年智慧整合照护模式的运行现况。结果 本研究共综述了7种老年智慧整合照护模式,从中提炼出了单一切入点、老年综合评估、个性化护理计划、跨学科病例会议、协调护理、病例管理、患者赋权7项核心要素,实践运行可有效满足供需双方需求,但在需求方、供给方、技术和系统层面仍存在较多阻碍因素。结论 国外老年智慧整合照护模式发展已相对成熟,中国可从中借鉴实践经验,结合中国养老福利供给特点,构建本土化智慧整合照护模式。
中图分类号:
[1] World Health Organization. Integrated Care for Older People (Icope) Implementation Framework: Guidance for Systems and Services[EB/OL].(2019-01-01)[2021-09-19].https://www.who.int/publications/i/item/9789241515993. [2] World Health Organization. Ageing and Health Unit[EB/OL].(2017-01-01)[2021-09-17]https://www.who.int/teams/maternal-newborn-child-adolescent-health-and-agein. [3] Sanchez-Rodriguez D, Piccard S, Dardenne N, et al.Implementation of the Integrated Care of Older People (ICOPE) App and ICOPE Monitor in Primary Care: A Study Protocol[J]. J Frailty Aging, 2021,10(3):290-296. DOI: 10.14283/jfa.2021.22. [4] Weiskittle R, Tsang W, Schwabenbauer A, et al.Feasibility of a COVID-19 Rapid Response Telehealth Group Addressing Older Adult Worry and Social Isolation[J]. Clin Gerontol,2022,45(1):129-143.DOI:10.1080/07317115.2021.1906812 [5] 洪燕,付晶晶,孔德辉,等.社区老年人线上社会参与现状及其影响因素的研究进展[J].护理学报,2021,28(14):12-16.DOI:10.16460/j.issn1008-9969.2021.14.012. [6] Ahmed A, van den Muijsenbergh METC, Mewes JC, et al. Untangling the Inter-relatedness within Integrated Care Programmes for Community-dwelling Frail Older People: A Rapid Realist Review[J]. BMJ Open, 2021,11(4):e43280. DOI: 10.1136/bmjopen-2020-043280. [7] 中华人民共和国中央人民政府. 中华人民共和国国民经济和社会发展第十四个五年规划和2035年远景目标纲要 [EB/OL]. (2021-03-13)[2021-09-17]. http://www.gov.cn/xinwen/2021-03/13/content_5592681.htm. [8] Deschodt M, Laurent G, Cornelissen L, et al.Core Components and Impact of Nurse-led Integrated Care Models for Home-dwelling Older People: A Systematic Review and Meta-analysis[J]. Int J Nurs Stud, 2020,105:103552. DOI:10.1016/j.ijnurstu.2020.103552. [9] Mateo-Abad M, Fullaondo A, Merino M, et al.Impact Assessment of an Innovative Integrated Care Model for Older Complex Patients with Multimorbidity: The CareWell Project[J]. Int J Integr Care, 2020,20(2):8. DOI:10.5334/ijic.4711. [10] Melchiorre MG, Papa R, Rijken M, et al.eHealth in Integrated Care Programs for People with Multimorbidity in Europe: Insights from the ICARE4EU project[J]. Health Policy, 2018, 122(1):53-63. DOI:10.1016/j.healthpol.2017.08.006. [11] Uittenbroek RJ, Kremer HPH, Spoorenberg SLW, et al.Integrated Care for Older Adults Improves Perceived Quality of Care: Results of a Randomized Controlled Trial of Embrace[J]. J Gen Intern Med, 2017,32(5):516-523. DOI:10.1007/s11606-016-3742-y. [12] Spoorenberg SLW, Wynia K, Uittenbroek RJ, et al.Effects of a Population-based, Person-centred and Integrated Care Service on Health,Wellbeing and Self-management of Community-living Older Adults: A Randomised Controlled Trial on Embrace[J].PLoS One,2018,13(1):e190751. DOI:10.1371/journal.pone.0190751. [13] Spoorenberg SL, Reijneveld SA, Uittenbroek RJ, et al.Health-related Problems and Changes after 1 Year as Assessed with the Geriatric ICF Core Set (GeriatrICS) in Community-living Older Adults Who Are Frail Receiving Person-centered and Integrated Care from Embrace[J]. Arch Phys Med Rehabil, 2019,100(12):2334-2345. DOI:10.1016/j.apmr.2019.02.014. [14] Janse B, Huijsman R, Fabbricotti IN.A Quasi-Experimental Study of the Effects of an Integrated Care Intervention for the Frail Elderly on Informal Caregivers' Satisfaction with Care and Support[J]. BMC Health Serv Res, 2014,14:140. DOI:10.1186/1472-6963-14-140. [15] Janse B, Huijsman R, de Kuyper R, et al. Delivering Integrated Care to the Frail Elderly: The Impact on Professionals' Objective Burden and Job Satisfaction[J]. Int J Integr Care, 2016,16(3):7. DOI:10.5334/ijic.2014. [16] Looman WM, Fabbricotti IN, de Kuyper R, et al. The Effects of a Pro-active Integrated Care Intervention for Frail Community-dwelling Older People: A Quasi-Experimental Study with the Gp-practice As Single Entry Point[J]. BMC Geriatr,2016,16:43.DOI:10.1186/s12877-016-0214-5. [17] Smartcare. Smartcare:Delivering Integrated eCare[EB/OL]. (2014-01-01)[2021-06-16].https://pilotsmartcare.eu/home/. [18] Kira S, Rosana A, Mayte H.Joining up ICT and Service Processes for Quality Integrated Care in Europe:Project Final Report[R].2016. [19] Anon.BeyondSilos[EB/OL]. (2014-02-01)[2021-09-19]. https://beyondsilos.eu/project/. [20] Piera-Jiménez J, Daugbjerg S, Stafylas P, et al.BeyondSilos, A Telehealth-enhanced Integrated Care Model in the Domiciliary Setting for Older Patients:Observational Prospective Cohort Study for Effectiveness and Cost-Effectiveness Assessments[J]. JMIR Med Inform, 2020,8(10):e20938. DOI:10.2196/20938. [21] Anon.CareWell Project [EB/OL]. (2014-06-01)[2021-09-19]. https://www.carewell-project.eu/home/. [22] Bakker FC, Persoon A, Bredie S, et al.The Care Well in Hospital Program to Improve the Quality of Care for Frail Elderly Inpatients: Results of a before-after Study with Focus on Surgical Patients[J]. Am J Surg,2014,208(5):735-746. DOI: 10.1016/j.amjsurg.2014.04.009. [23] Mateo-Abad M, González N, Fullaondo A, et al.Impact of the Care Well Integrated Care Model for Older Patients with Multimorbidity:A Quasi-experimental Controlled Study in the Basque Country[J]. BMC Health Serv Res, 2020,20(1):613. DOI: 10.1186/s12913-020-05473-2. [24] de Batlle J, Massip M, Vargiu E, et al. Implementing Mobile Health-enabled Integrated Care for Complex Chronic Patients: Intervention Effectiveness and Cost-effectiveness Study[J]. JMIR Mhealth Uhealth, 2021,9(1):e22135. DOI:10.2196/22135. [25] Colomina J, Drudis R,Torra M,et al.Implementing Mhealth-Enabled Integrated Care for Complex Chronic Patients with Osteoarthritis Undergoing Primary Hip or Knee Arthroplasty: Prospective, Two-arm, Parallel Trial[J]. J Med Internet Res, 2021,23(9): e28320. DOI: 10.2196/28320. [26] Kim H, Jung Y, Kim G, et al.Effectiveness of a Technology-enhanced Integrated Care Model for Frail Older People: A Stepped-wedge Cluster Randomized Trial in Nursing Homes[J]. Gerontologist, 2021,61(3):460-469. DOI:10.1093/geront/gnaa090. [27] Choi H, Jung Y, Kim H.Implementation Fidelity of the Systems for Person-centered Elder Care (Spec): A Process Evaluation Study[J]. Implement Sci, 2021,16(1):52. DOI: 10.1186/s13012-021-01113-3. [28] Melchiorre MG, Lamura G, Barbabella F. eHealth for People with Multimorbidity: Results from the Icare4Eu Project and Insights from the “10 e's” by Gunther Eysenbach[J]. PLoS One, 2018, 13(11):e207292. DOI:10.1371/journal.pone.0207292. [29] Steele Gray C, Barnsley J, Gagnon D, et al.Using Information Communication Technology in Models of Integrated Community-based Primary Health Care: Learning from the iCOACH case Studies[J]. Implement Sci, 2018,13(1):87. DOI:10.1186/s13012-018-0780-3. [30] Delmastro F, Dolciotti C, Palumbo F, et al.Long-term Care: How to Improve The Quality of Life with Mobile and e-Health Services[C].// 2018 14th International Conference on Wireless and Mobile Computing, Networking and Communications (WiMob). Limassol: IEEE, 2018:8. [31] Doyle J, Murphy E, Gavin S, et al.A Digital Platform to Support Self-management of Multiple Chronic Conditions (ProACT): Findings in Relation to Engagement during a One-Year Proof-of-Concept Trial[J]. J Med Internet Res, 2021,23(12): e22672. DOI:10.2196/22672. [32] Kastner M, Sayal R, Oliver D, et al.Sustainability and Scalability of a Volunteer-based Primary Care Intervention (Health Tapestry): A Mixed-methods Analysis[J]. BMC Health Serv Res, 2017,17(1):514. DOI:10.1186/s12913-017-2468-9. [33] Valaitis R, Cleghorn L, Dolovich L, et al.Examining Interprofessional Teams Structures and Processes in the Implementation of a Primary Care Intervention (Health Tapestry) for Older Adults Using Normalization Process Theory[J]. BMC Fam Pract, 2020,21(1):63. DOI:10.1186/s12875-020-01131-y. [34] Vestjens L, Cramm JM, Nieboer AP.An Integrated Primary Care Approach for Frail Community-dwelling Older Persons: A Step Forward in Improving the Quality of Care[J]. BMC Health Serv Res, 2018,18(1). DOI:10.1186/s12913-017-2827-6. [35] World Health Organization.Integrated care for Older People (ICOPE) Implementation Pilot Programme: Findings From The ‘Ready' Phase[G]. 2022. |
[1] | 毛欣楠, 徐林燕, 赵磊, 许丽娟. 医院衰弱风险评分在老年住院患者不良结局预测中的应用进展[J]. 护理学报, 2022, 29(24): 18-21. |
[2] | 邹婧杰, 王云翠, 覃四琪. 本科老年护理人才胜任力培养的国内外研究进展[J]. 护理学报, 2022, 29(24): 22-26. |
[3] | 杨奕婷, 彭凌. 老年痴呆症患者医院-社区-家庭延续护理发展及启示[J]. 护理学报, 2022, 29(24): 32-37. |
[4] | 罗姣, 刘艳丽, 周丽君, 魏齐斐, 张奇, 刘小菲, 王鑫源. 代际方案在老年痴呆患者中的应用研究进展[J]. 护理学报, 2022, 29(22): 37-40. |
[5] | 程维, 程蕾, 戴喜花, 陈玉平. 基于奥马哈问题分类系统老年综合评估指标体系的构建[J]. 护理学报, 2022, 29(22): 69-73. |
[6] | 李芳, 潘晓彦, 刘婷, 王敏. 健康服务领域老年人年龄歧视研究进展[J]. 护理学报, 2022, 29(22): 41-45. |
[7] | 杨娇娇, 彭丽丽, 王三香, 李翊澜, 石奥利, 田甜, 杨金花. 模拟社会生活照护对养老机构老年痴呆患者激越行为的影响[J]. 护理学报, 2022, 29(17): 75-78. |
[8] | 王英杰, 周欣, 王玉, 乔然, 王晓晶. 高龄衰弱患者基于健康体适能评价模型抗阻运动的效果观察[J]. 护理学报, 2022, 29(16): 65-70. |
[9] | 苏淑文, 张建明, 邓瑞冰, 李霞. 老年人口腔健康相关生活质量及影响因素研究进展[J]. 护理学报, 2022, 29(14): 31-36. |
[10] | 张雨, 刘芳丽, 蔡方方, 高孟娟, 袁举, 成巧梅. 经验性回避在痴呆患者家庭照顾者附属病耻感与照顾负担间的中介作用[J]. 护理学报, 2022, 29(14): 58-63. |
[11] | 韩婷, 钱绪芬, 王庆芳, 程新春, 郭俊梅, 肖江琴. 基于Logistic回归和决策树模型的老年住院患者肌少症风险的影响因素分析[J]. 护理学报, 2022, 29(12): 56-62. |
[12] | 陈梦然, 王秀丽, 张叶, 张宇, 陈潇, 张鑫炎, 刘东玲. 沉浸式虚拟现实技术评估轻度认知障碍患者空间导航能力的研究进展[J]. 护理学报, 2022, 29(7): 40-43. |
[13] | 许敏铮, 夏丽莉. 228例住院老年患者跌倒后生存状况及死亡危险因素的COX回归分析[J]. 护理学报, 2022, 29(7): 63-68. |
[14] | 张智月, 董奥, 冉明, 张国琴. 孤独在老年慢性病患者社会支持与自我感知老化间的中介效应[J]. 护理学报, 2022, 29(4): 59-63. |
[15] | 李惊鸿, 黄欢欢, 谢颖, 曹松梅, 肖明朝, 赵庆华. 369例重庆社区高血压老年患者衰弱与营养不良共病现状及影响因素分析[J]. 护理学报, 2021, 28(22): 70-74. |
|