体弱老年患者。综合服务提供新模式。
Frail elderly patients. New model for integrated service delivery.
作者信息
Hébert Rejean, Durand Pierre J, Dubuc Nicole, Tourigny André
机构信息
Research Centre on Aging, Sherbrooke, QC.
出版信息
Can Fam Physician. 2003 Aug;49:992-7.
PROBLEM BEING ADDRESSED
Given the complex needs of frail older people and the multiplicity of care providers and services, care for this clientele lacks continuity.
OBJECTIVE OF PROGRAM
Integrated service delivery (ISD) systems have been developed to improve continuity and increase the efficacy and efficiency of services.
PROGRAM DESCRIPTION
The Program of Research to Integrate Services for the Maintenance of Autonomy (PRISMA) is an innovative ISD model based on coordination. It includes coordination between decision makers and managers of different organizations and services; a single entry point; a case-management process; individualized service plans; a single assessment instrument based on clients' functional autonomy, coupled with a case-mix classification system; and a computerized clinical chart for communicating between institutions and professionals for client monitoring.
CONCLUSION
Preliminary results on the efficacy of this model showed a decreased incidence of functional decline, a decreased burden for caregivers, and a smaller proportion of older people wishing to enter institutions.
所解决的问题
鉴于体弱老年人的复杂需求以及护理提供者和服务的多样性，对这一群体的护理缺乏连续性。
项目目标
已开发出综合服务提供（ISD）系统，以改善连续性并提高服务的效力和效率。
项目描述
维持自主性综合服务研究项目（PRISMA）是一种基于协调的创新性ISD模式。它包括不同组织和服务的决策者与管理者之间的协调；单一入口点；个案管理流程；个性化服务计划；基于客户功能自主性的单一评估工具，以及病例组合分类系统；还有一个用于机构和专业人员之间沟通以监测客户情况的计算机化临床图表。
结论
该模式有效性的初步结果显示，功能衰退发生率降低，护理人员负担减轻，希望入住机构的老年人比例减小。
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