许多卫生系统已经实施了综合护理,作为医疗服务的替代方法,更适合复杂,长期需求。本文的目的是分析德国老年病医院综合护理的实施情况,并探讨使用基于“情境-机制-结果”的模型是否可以提供有关何时以及为什么可以实现有益结果的见解。
我们对医院雇用的卫生专业人员进行了15次半结构化访谈。使用基于“上下文-机制-结果”的模型对数据进行定性分析。具体来说,机制被定义为综合护理干预的不同组成部分,并根据Wagner的慢性护理模式(CCM)进行分类.背景被理解为将机制付诸实践的背景,并由实施过程中遇到的障碍和促进者来描述。这些是根据Grol和Wensing的实施模型(IM)的六个级别进行分类的:创新,个别专业人士,病人,社会背景,组织背景和经济和政治背景。结果被定义为由机制和上下文触发的效果,并根据世界卫生组织定义的护理质量的六个维度进行分类,即有效性,效率,可访问性,以病人为中心,公平和安全。
综合护理干预包括三个主要组成部分:特定的报销系统(“早期复杂的老年康复”),多学科合作,和全面的老年评估。报销制度在强制性治疗次数方面的不灵活性导致了过度,服务不足和滥用。多学科合作受到高工作量的阻碍,这导致了工作流程中的浪费。全面的老年病评估补充了家庭成员提供的信息,这有助于降低不良事件的可能性。
我们建议更加关注尝试了解干预组件如何与上下文因素相互作用,合并,导致积极和/或消极的结果。
Many health systems have implemented integrated care as an alternative approach to health care delivery that is more appropriate for patients with complex, long-term needs. The objective of this article was to analyse the implementation of integrated care at a German geriatric hospital and explore whether the use of a \"context-mechanisms-outcomes\"-based model provides insights into when and why beneficial outcomes can be achieved.
We conducted 15 semi-structured interviews with health professionals employed at the hospital. The data were qualitatively analysed using a \"context-mechanisms-outcomes\"-based model. Specifically, mechanisms were defined as the different components of the integrated care intervention and categorised according to Wagner\'s Chronic Care Model (CCM). Context was understood as the setting in which the mechanisms are brought into practice and described by the barriers and facilitators encountered in the implementation process. These were categorised according to the six levels of Grol and Wensing\'s Implementation Model (IM): innovation, individual professional, patient, social context, organisational context and economic and political context. Outcomes were defined as the effects triggered by mechanisms and context, and categorised according to the six dimensions of quality of care as defined by the World Health Organization, namely effectiveness, efficiency, accessibility, patient-centeredness, equity and safety.
The integrated care intervention consisted of three main components: a specific reimbursement system (\"early complex geriatric rehabilitation\"), multidisciplinary cooperation, and comprehensive geriatric assessments. The inflexibility of the reimbursement system regarding the obligatory number of treatment sessions contributed to over-, under- and misuse of services. Multidisciplinary cooperation was impeded by a high workload, which contributed to waste in workflows. The comprehensive geriatric assessments were complemented with information provided by family members, which contributed to decreased likelihood of adverse events.
We recommend an increased focus on trying to understand how intervention components interact with context factors and, combined, lead to positive and/or negative outcomes.