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首页> 外文期刊>International Journal of Integrated Care >From a national program to local implementations: how to coordinate patient-centred care for elderly taking territorial specificities into account
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From a national program to local implementations: how to coordinate patient-centred care for elderly taking territorial specificities into account

机译：从国家计划到地方实施：如何在考虑地区特殊性的情况下协调以患者为中心的老年人护理

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Introduction : In the context of an ageing population and very fragmented health and social care systems, the French ministry of Health is testing a national program since 2013. It aims to tackle challenges faced at all levels: how to coordinate care pathways for elders at risk of losing their autonomy? We'll focus on the implementation of organisations supporting coordination of health and socialcare professionals around the patients and caregivers, at a territorial level. Practice change implemented For each territory, implementation of: - A single organization accessible for professionals, patients and caregivers; - A unique phone number; - One information system; - New roles and responsibilities. Aim and theory of change : The program aims to: Avoid breaks in elderly care pathway; Improve quality of life of elderly and their caregivers, by reducing hospitalisations, time spent in hospitals, and improving care conditions; Orient professionals’ practices and create favorable conditions towards more coordination, cooperation and cross-cutting practices. Targeted population and stakeholders : Targets: elderly from 75 year old and above, at risk of losing their autonomy. Stakeholders: regional authorities, local social insurance organisms, professionals’ representatives unions, professionals and coordination actors, the ministry of health. Timeline : The program was launched in 2013. A first wave of 9 pilot’s territories was implemented in 2015. A second was launched in 2014 with 9 other territories. The program is ending in December 2018. Highlights : General objectives and framework are coupled with needs assessments, diagnostics and roadmaps elaborated by territorial actors. This is a key lever for embedding multiple actors who were, and still are, used to work in silos. It also helps formalizing already existing coordination and cooperation. Significant impacts on health outcomes have not been identified yet, as the program is too recent. However, a national evaluation confirms the needs of professionals to be supported, interest for transition management between settings and highlights valuable new roles focused on care coordination for patients and caregivers. Sustainability : All coordination organizations are now enshrined in law since 2016. The ministry displays a strong willingness for convergence and mutualisation of what already exists. At all levels, professional’s practices are encouraged to evolve towards more cooperation and shared practices. Transferability : The program offers a flexible framework for action, enabling implementations taking into account territorial specificity and context. It is customizable enough to permit appropriation by actors, and generalize these initiatives. Conclusions : Several recommendations can help stakeholders better organize their services by identifying: success factors in the running of projects; Levers improving responses related to accessibility, scheduling, coordination or implementation in a territory; Levers supporting a continuous improvement process based on a relevant assessment of implemented actions. Discussions : The program relies on a holistic and participative approach taking into account territorial specificities, but also the complex problematic the Ministry aims to tackle. The program achieved to embed professionals and change positively their way of working: information sharing, better knowledge of services delivered, capacity of mobilising various experts around the patients, implementation of new solutions, etc. Lessons learned : An impact evaluation is planned for end of 2018.
机译：简介：在人口老龄化和卫生与社会护理体系非常分散的背景下，法国卫生部自2013年以来一直在测试一项国家计划。该计划旨在应对各个层面面临的挑战：如何协调面临风险的老年人的护理途径失去自治权？我们将重点关注在区域范围内支持在患者和护理人员周围协调医疗保健和社会护理专业人员的组织的实施。实施实践变更对于每个地区，实施以下内容：-可供专业人员，患者和护理人员使用的单一组织; -唯一的电话号码; -一个信息系统; -新的角色和职责。变革的目的和理论：该计划旨在：避免中断老年护理途径;通过减少住院，减少住院时间和改善护理条件，改善老年人及其护理人员的生活质量;指导专业人员的实践，并为进一步的协调，合作和跨领域实践创造有利条件。目标人群和利益相关者：目标人群：75岁及以上的老年人，可能会失去自主权。利益相关者：地区政府，地方社会保险机构，专业人士的代表工会，专业人士和协调人员，卫生部。时间表：该计划于2013年启动。2015年实施了第一批9个领地的试点。第二次于2014年启动了其他9个试点的试点。该计划于2018年12月结束。要点：总体目标和框架与领土参与者制定的需求评估，诊断和路线图结合在一起。这是嵌入多个曾经和现在仍在孤岛工作的参与者的关键杠杆。它还有助于形式化已经存在的协调与合作。由于该计划太新，因此尚未确定对健康结果的重大影响。但是，一项国家评估确认了需要专业人员支持的需求，对场所之间过渡管理的兴趣，并强调了针对患者和护理人员护理协调的宝贵新角色。可持续性：自2016年以来，所有协调组织均已纳入法律。该部表现出强烈的意愿，要求已存在的事物进行融合和相互融合。在各个级别上，都鼓励专业人员的实践向更多的合作和共享实践发展。可移植性：该计划提供了一个灵活的行动框架，使实施时可以考虑到领土的特殊性和背景。它具有足够的可自定义性，以允许参与者分配资金并推广这些计划。结论：通过确定以下几点建议，可以帮助利益相关者更好地组织服务：确定项目运行的成功因素;改善与区域内的可访问性，日程安排，协调或实施相关的响应;基于对已执行操作的相关评估，支持持续改进过程的杠杆。讨论：该计划既要考虑到领土的特殊性，又要考虑到整体性和参与性，同时还要考虑该部要解决的复杂问题。该计划实现了嵌入专业人员并积极改变其工作方式的目的：信息共享，更好地了解所提供的服务，动员各种专家围绕患者开展活动的能力，实施新解决方案等。经验教训：计划在年底前进行影响评估2018。

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