上海市社区安宁疗护试点自主服务项目开展现况研究

Hospice Care Pilot Program Independently Pioneered by Community Health Centers in Shanghai:a Cross-sectional Survey

背景安宁疗护全方位照护内容中,包括生存期评估和心理疏导在内的许多契合安宁疗护理念、符合患者需求的试点自主服务,因缺少收费依据无法纳入医保,成为制约安宁疗护发展的瓶颈问题。目的系统调查社区卫生服务中心实际开展但未纳入收费和医保的安宁疗护自主服务项目的开展情况,为规范安宁疗护服务内容、完善安宁疗护服务定价收费机制提供科学依据。方法于2020年7—10月,采用典型抽样法,在上海市各区选取安宁疗护业务量较大的1~2家社区卫生服务中心作为调查机构,最终调查30家机构。采用自行设计的“上海市安宁疗护试点自主服务项目调查表”对纳入机构开展调查,量表包括住院安宁疗护服务、居家安宁疗护服务两个方面的5类35项服务项目,由各机构安宁疗护服务负责人根据过去一年服务开展情况进行填写。结果29家(96.7%)机构的调查表被有效回收,其中28家(96.6%)开展了住院安宁疗护服务,开展项目中位数为27(15)项,25家(86.2%)开展了居家安宁疗护服务,开展项目中位数为25(15)项。5类服务项目在住院安宁疗护服务、居家安宁疗护服务中的开展项目数比较,差异无统计学意义(P>0.05)。中心城区、近郊区、远郊区社区卫生服务中心的住院安宁疗护服务、居家安宁疗护服务开展项目数比较,差异无统计学意义(P>0.05)。评估、舒适照护、安宁疗护适宜技术、心理支持、人文关怀5类服务项目,在住院安宁疗护服务中的平均开展比例分别为85.7%、78.6%、48.6%、88.4%、67.5%,在居家安宁疗护服务中的平均开展比例分别为86.3%、60.0%、42.0%、84.0%、62.0%。结论社区卫生服务中心的试点自主服务项目开展较广泛,服务可及性和区域均衡性较好。亟须进一步规范服务项目内容,制定临床标准,完善价格收费机制,改革支付方式,以激励机构和医务人员规范提供安宁疗护服务。

Background Survival assessment,psychological counseling and other services included in the comprehensive hospice care program conform to the hospice care philosophy,and may be independently delivered to patients to satisfy their needs in a pioneering approach by some health institutions,but the expenses of them could not be reimbursed by health insurance due to lack of an official basis for charging,which may be a bottleneck restricting the development of hospice care.Objective To systematically assess the hospice care services whose expenses are ineligible for reimbursement by health insurance independently provided by community health centers(CHCs)in a pioneering approach,offering a basis for improving the services and price system of hospice care.Methods From July to October 2020,by use of typical sampling,one or two CHCs with relatively heavy workload of hospice care were selected from each district of Shanghai,then from which 30 were selected to attend a survey for understanding the implementation status of hospice care using a self-developed questionnaire named Pilot Hospice Care Services Pioneered by Shanghai Community Health Centers,involving inpatient and home hospice care(35 services belonging to five types).Individuals in charge of hospice care delivery completed the questionnaire according to the status of hospice care implemented in their CHCs in the past year.Results The survey obtained a response rate of 96.7%(29/30).Among the respondent 29 CHCs,28(96.6%)delivered inpatient palliative care services,and the median number of services available was 27(15);25(86.2%)provided home hospice care services,with 25(15)as the median number of services available.There was no significant difference in the number of services belonging to five types delivered for inpatients and at home(P>0.05).There were also no significant differences in the number of inpatient and home hospice care services delivered by CHCs in central urban,suburban,and exurban districts(P>0.05).Among the hospice care services delivered for inpatients,the average proportions of five types of services,namely assessment services,comfort care,appropriate technology of hospice care,psychological support and humanistic care were 85.7%,78.6%,48.6%,88.4%and 67.5%,respectively.Among the hospice care services delivered at home,the average proportions of above-mentioned five types of services were 86.3%,60.0%,42.0%,84.0%and 62.0%,respectively.Conclusion Hospice care services have been widely implemented in Shanghai's CHCs with good availability and insignificant inter-district differences.To incentivize the CHCs and medical workers to provide hospice care,there is an urgent need to further standardize the hospice care services,develop relevant quality criteria,improve the price system,and reform the payment method.