出版社：Utrecht University, Maastricht University, Groningen University
摘要：Introduction : The Accessible Quality Healthcare (AQH) project in Kosovo is funded by the Swiss Agency for Development and Cooperation (SDC) and implemented by Swiss Tropical and Public Health Institute (Swiss TPH) and Save the Children. It supports the implementation of health reform, with a focus on Primary Health Care (PHC) and non-communicable diseases, in 12 municipalities of Kosovo. In Kosovo the complex needs of older people are often neglected, and providing person-centred care is a challenge when: there is limited collaboration between health and other sectors; patient record-keeping is generally weak; and care is often provided based on what services each sector wants to provide rather than what services the patient actually needs.The Municipality of Fushe Kosova is piloting an integrated care model that aims to improve the quality of care provided for patients over the age of 65yrs that have been diagnosed with Type 2 Diabetes, through better coordination of services provided by the health and social sectors. Methodology and Discussion : A key success factor of the progress made so far has been the establishment of a municipality-level multi-sectoral working group (WG), with representatives from: Health Sector, Social Services, local Non-Government Organizations, the Patients' Rights Association, and the Association of Retirees. This participatory approach was used as the basis for looking at how the coordination of services between health and social sectors, including community involvement, could be improved by adopting a patient-centered approach. An international expert has supported the WG through the process and, whilst the expert brings their experience and international best practice, it is the local multi-sectoral WG that ensures feasibility and sustainability of the integrated care model at Municipality level. The project has organized several trainings for medical staff on the WHO protocols for the management of diabetes, and is providing glucometers for self-management to identified patients. Health education and patient information materials have been also been produced as health literacy is generally recognized as being low. The most innovative intervention in the Kosovo context has been the development of a geriatric assessment tool, which comprises a questionnaire to collect information about health and social status of patients. For the first time, a joint assessment is now carried out by both a nurse and social worker in the patients’ home. Based on the findings of the assessment, a joint individualised patient care plan is then developed by a multi-disciplinary team comprising Family Medicine doctors, nurses and social workers. A Monitoring and Evaluation framework has been developed and this is now being used to monitor the implementation of activities and evaluate to what extent the quality of care for older people with Type 2 Diabetes has been improved. Conclusion : Integrated services, person-centered care and care-planning are all new concepts in the Kosovo context. The participatory approach of having a multi-sectoral WG lead the reform and ensure that all activities are locally – driven and entirely appropriate for the local context has been a huge asset in ensuring a clear commitment to implementation of integrated care model.
关键词：integrated care ; elderly care ; Type 2 Diabetes
