Bell Stephanie H, Tracy C Shawn, Upshur Ross E G
Primary Care Research Unit, Department of Family and Community Medicine, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada.
BMJ Case Rep. 2011 Mar 15;2011:bcr0720103154. doi: 10.1136/bcr.07.2010.3154.
Mr K is an 89-year-old married man with a number of comorbid conditions and multiple recent falls. He was referred to the IMPACT clinic (Interprofessional Model of Practice for Aging and Complex Treatments) as his primary care physician was concerned about his declining health and the growing care giver burden on his wife. Mr K's condition was deteriorating while the complexity of his case was increasing; therefore, an in-depth team assessment was sought to determine the best management plan and to assess his capacity to remain at home (his expressed preference). The IMPACT team met with Mr K and his wife for a 2 h interprofessional assessment. A comprehensive care plan was developed including specific recommendations for implementing change. After the visit to the IMPACT clinic, Mr K's care was returned to his regular family physician.
K先生是一位89岁的已婚男性,患有多种合并症,近期多次跌倒。他被转诊至IMPACT诊所(老龄化与复杂治疗跨专业实践模式),因为他的初级保健医生担心他日益下降的健康状况以及他妻子日益加重的照顾负担。K先生的病情在恶化,而他的病例复杂性却在增加;因此,寻求进行深入的团队评估,以确定最佳管理方案,并评估他居家(他明确表示的偏好)的能力。IMPACT团队与K先生及其妻子进行了一次长达2小时的跨专业评估。制定了一份全面的护理计划,包括实施变革的具体建议。在就诊IMPACT诊所后,K先生的护理工作又交回给他的常规家庭医生。