Introdução: A atenção domiciliar (AD) vem ganhando destaque em função do envelhecimento da população e do predomínio das doenças e agravos não transmissíveis, como uma alternativa aos modos já instituídos de cuidado, podendo ser uma modelagem potente que permite a transformação das práticas de saúde, produzindo uma assistência que favorece a criação de vínculo entre trabalhador e usuário, o acolhimento, a humanização e o desenvolvimento de corresponsabilidade. Em 2011, foi criada a política nacional de atenção domiciliar, regulamentada pela Portaria no 963/GM/MS de 27 maio de 2013, a qual estabelece diretrizes bastante específicas acerca dos serviços de AD e institui o cofinanciamento federal, o que poderá implicar numa ampliação significativa dos serviços existentes. Objetivo: Analisar experiências de atenção domiciliar do SUS, suas potencialidades e desafios na produção do cuidado, bem como os efeitos iniciais da Portaria nº 963/GM/MS, de 27 de maio de 2013 sobre as iniciativas municipais. Métodos: Pesquisa qualitativa de abordagem cartográfica, onde foram explorados três serviços de AD do SUS, no Estado de São Paulo. Com o intuito de mapear analisadores significativos para a potencialização da atenção domiciliar como arranjo assistencial para produção do cuidado orientada à integralidade, diferentes iniciativas compuseram a cartografia, tais como entrevistas, observação participante e construção de diário de campo. Resultados e Discussão: A AD pode ser um importante dispositivo para análise das tensões, apostas e desafios que emergem na prática dos serviços de saúde, bem como dar a visibilidade aos vazios assistenciais na rede. A portaria ministerial quando tomada como dispositivo, faz normatizações que vem gerando tensões junto aos SAD, ao mesmo tempo em que estes criam linhas de fuga ao produzirem outros arranjos. Conclusão: A AD pode ser uma modelagem substitutiva ao modelo hospitalocêntrico, ao mesmo tempo que pode ser uma estratégia ao enfrentamento de dificuldades que a atenção básica sofre, o que pode orientar a construção de arranjos mais permeáveis à realidade brasileira. A AD pode ser um dispositivo fundamental para dar visibilidade aos vazios de atenção e para aprofundar a discussão sobre a rede e dispositivos de gestão do cuidado. / Introduction: Home care (HC) is gaining prominence due to the aging population and the prevalence of non-communicable diseases and injuries, as an alternative to established modes of care, being regarded as a powerful modeling organization that enables the transformation of health care practice, producing a company committed to creating relationship between worker and patient with hosting, humanization care and the development of responsibility. In 2011, the national policy of home care, regulated by Ordinance 963/GM/MS of May 27, 2013, which sets very specific guidelines about HC services and establishes the federal co-financing, which may involve a significant expansion of the services. Objective: To analyze home care experiences of the NHS, its potentials and challenges in care production, as well as the initial effects of Ordinance No. 963/GM/MS of 27 May 2013 on municipal initiatives. Methods: A qualitative study of cartographic approach, where three services of HC, located in the State of São Paulo, were explored. In order to map to significant analyzers to potentiation of home care as a medical care arrangement for care production oriented to the integrality, various initiatives were included in the mapping, such as interviews, participant observation and construction of a field diary. Results and Discussion: HC can be an important dispositive for analysis of tensions, bets and challenges emerging in the practice of health services, as well as giving visibility to the empty assistance in the health net. The ministerial order when taken as a dispositive, make regulations that has sparked tensions with the HC services, while they create other ways by producing other arrangements. Conclusion: HC may be a substitutive model of hospital-centered model, while it may be a strategy to cope with difficulties that primary care suffers, which can guide the construction of more permeable arrangements to Brazilian reality. HC can be a key device for providing visibility to empty the attention and further discuss about health network and managed care devices.

隨著老年人口的增加，首要面對的議題即為慢性病罹病率的劇增，而其中又以近年來大家所最為關注的失智症為最。由於失智症患者的記憶力、語言與自我照顧能力會隨著病程而逐漸退化，使得照顧者在照顧上的負荷更勝一般失能老人的照顧者。因此，本研究欲從失智老人家庭照顧者的觀點，瞭解其選擇使用居家服務之經驗。 據此，本論文之研究目的在於：一、瞭解失智老人家庭使用居家服務之原因。二、探索失智老人家庭照顧者使用居家服務前後的照顧項目變化，並進而探究居家服務對照顧者及老人之功能。三、從失智老人家庭照顧者的觀點出發，探索何謂好的居家服務，以及其他失智症相關的福利需求。四、依據研究結果，作為服務單位改進措施及政策規劃之參考。 本研究使用質性取向的研究方法，由台北市兩間居家服務協助提供適合本研究之研究對象，採用半結構式的深度訪談法進行資料蒐集，共計訪談十位照顧者。主要的研究結果如下： 一、失智老人家庭照顧者普遍都有生理、心理及社會層面的負荷，這些負荷包括照顧壓力太大、自己的時間受到限制及照顧與工作無法兼顧；而當照顧者面臨到老人因素、照顧者因素及照顧人力因素等三個因素的困難時，就會傾向選擇其他的替代方式來照顧老人。 二、對失智老人家庭照顧者而言，居家服務除可分擔自己的照顧責任、增進社會接觸、補充照顧人力不足之問題以及增加可彈性運用之時間外，更能讓自己對老人狀況有所掌握，並能減緩自己與老人間的緊張關係；而居家服務對失智老人亦有所幫助，尤其是在「增加老人社會接觸」與「增進老人生活自理能力」兩方面。但僅對於輕、中度的失智老人有幫助，對於失智重度以上甚至生活自理能力缺損嚴重的老人而言，幫助則有限。 三、對於失智老人家庭照顧者來說，好的服務員應具備：要有服務熱忱、有愛心、能注重細節，並能感受老人的需求；要有好的服務態度；要有專業素養；及要能讓老人信任等特質；而照顧者眼中好的居家服務單位，則應具備：為求服務員穩定提供服務，對於服務員的休假或請假應有相關規定；應要求服務員要定期回報服務狀況；及應定期安排服務員受訓等條件。 / With the increase of elderly population, the rapid growth of the morbidity of chronic diseases has become the most important issue. In recent years, most people pay attention to the elderly with dementia because their memory, language and self-care capacity will be gradually degraded during the course of the disease. The burden of caregivers taking care of the elderly with dementia is much heavier than the general caregivers of the disabled elderly. Therefore, this study aimed to understand the viewpoints of caregivers taking care of the elderly with dementia about their experiences in choosing to use the home-care services. Accordingly, the purposes of this study are the following: first, understanding the reasons of using home-care services of the family with the elderly with dementia; second, exploring the changes of the caregivers taking care of the elderly with dementia before and after using the home-care services; third, exploring what are good home-care services and other dementia-related welfare needs from the viewpoints of caregivers taking care of the elderly with dementia; forth, providing suggestions for policy making and the improvement of the home-care services providers based on the research findings. This study used the qualitative research approach, and collected data from two home-care services providers and included semi-structured in-depth interviews with ten caregivers of the elderly with dementia. The research findings were listed below: First, the caregivers of the elderly with dementia generally had physical, psychological and social dimensions of burden including pressure, limited time and being not able to take charge of caregiving and work simultaneously. When caregivers faced the difficulties of the above three factors such as the elderly with dementia, caregivers and caregiving manpower, they tended to choose other alternatives to provide caregiving for the elderly. Second, for the caregivers of the elderly with dementia, they could understand the situation of the elderly and reduce their tensions between themselves and the elderly in addition to sharing their duty of caregiving, improving social contact, supplying manpower, and enhancing the time flexibility by providing home-care services. Home-care services also could help the elderly with dementia particularly in the dimensions of “social contact “and “promotion of daily living”. However, it was only for the elderly with mild to moderate degree of dementia; for the elderly with severe dementia and more severe impairment of daily living, the benefit was limited. Third, from the viewpoints of family caregivers of the elderly with dementia, a good home-care worker should have the enthusiasm for providing services, be compassionate and attentive to details, be able to understand the needs of the elderly, have a good attitude, be professional, and be able to be trusted by the elderly. In addition, a good home-care services provider should provide the stable quality of services, have the relevant regulations, require caregivers to report services status regularly and train the home-care workers periodically.

When care is moved from the hospital to the home the demands for high quality care still remain. For problems arising from the geographical separation of patients and professional caregivers, information and communication technology may offer important solutions. The overall aim of this thesis was to describe relevant requirements, to design and implement an IT-based system, and finally to evaluate the system’s influence on symptom control and support for both patients/next-of-kin and professional caregivers in advanced home healthcare. Of importance were needs in basic as well as advanced home healthcare, as were usability perspectives of both patients and professional caregivers. Requirement areas such as security, mobility, and responsibility, which should be considered when monitoring patients in the home, were identified. A prototype system for everyday assistance for diabetes patients was designed, and a system for frequent pain assessment for palliative home healthcare patients using a pain diary, digital pen and mobile Internet technology, was developed and evaluated through a qualitative content analysis approach. Twelve palliative cancer patients and six professional caregivers participated. The data collected included an ease-of-use questionnaire, and interviews with patients, spouses and professional caregivers. Patients expressed increased and improved contact with the caregivers, increased participation in their own care, a sense of increased security, and easiness in using the equipment in spite of severe illness and difficulties in comprehending the technology and system intervention. The professional caregivers showed a shifting outlook towards the pain assessment method; an initial cautious outlook due to low expectations of the patients’ abilities to use the pain assessment method and the caregivers’ own reluctance to use the system and change their way-of-working. Despite this, the professional caregivers experienced positive outcomes in terms of an increased awareness of pain, and positive patient influences including increased participation in their care, increased security and improved changes in pain treatment as a response to reported pain assessments. In conclusion, the networked digital pen system provided an effortless method for pain assessment and had positive influences on the care. The results imply that digital pen technology is suitable for the assessment of symptoms by palliative patients since these patients often have a limited capacity to handle technology due to their state of health. / On the day of the public defence date of the doctoral thesis the status of article III and IV was Submitted.

The aim of this thesis was to study elderly people’s experiences of and approach to their usage of home care services with tax deduction. The aim was also to describe how elderly people reason about their underlying motives of using home care service with tax deduction. The study is based on six qualitative interviews with people between the ages of 65 and 80, living in Nacka, Sweden. This thesis is a collaboration with Stiftelsen Stockholms läns Äldrecentrum/ Stockholm Gerontology Center and part of their follow up study concerning simplified administration for elderly people applying for home care services in Nacka. The theory of rational choice was used in the analysis of the results. The primary results showed that elderly people’s usage of home care services with tax deduction was limited though regular and consist mainly of basic domestic work. The overall experiences of using home care services with tax deduction were positive and described in terms of satisfaction and as a possibility of independence and influence regarding their needs of services and how they were executed. The results indicate that the usage of home care services with tax deduction is partly based on elderly people’s lack of confidence in publicly-financed elderly care. Due to the distrust in elderly care and the self-determing factors home care services with tax deduction generated, their choice of using home care services with tax deduction seemed more appealing than publicly-financed home care services.

Hemsjukvårdscentralen began its work from Tunåsens Hospital in Uppsala in 1962, with the purpose to give conomic support to people who nursed their chronic sick relatives in home. Hemsjukvårdscentralen ended its work in 1987, and delivered its archive to the County council of Uppsala in 1988. About half of the archive consisted of medical records of the patients who had received economical support, and many of the archival records was considered as ”work papers”, non-archival records that could be discarded. Two obvious problems emerge from the organizing of the records. The first problem was the difficulty to keep the principle of provenance while making a access point to the archive, especially when it's common in Sweden to use the double principle of provenance: a fusion between the respect des fonds, the external order, and the strukturprinzip, the internal order. The second problem was to compile a complete history of the Hemsjukvårdscentralen's activities during its active years, and therefor decide which records to save and which records to discard – and which records who had a value for the future. This analysis therefore focus on the series F1 (the medical records) and F6 (the ”work papers”). This is a one year master's thesis in archival science.

This thesis develops quantitative methods which incorporate transportation modeling for tactical and operational home health logistics planning problems. We define home health nurse routing and scheduling (HHNRS) problems, which are dynamic periodic routing and scheduling problems with fixed appointment times, where a set of patients must be visited by a home health nurse according to a prescribed weekly frequency for a prescribed number of consecutive weeks during a planning horizon, and each patient visit must be assigned an appointment time belonging to an allowable menu of equally-spaced times. Patient requests are revealed incrementally, and appointment time selections must be made without knowledge of future requests. First, a static problem variant is studied to understand the impact of fixed appointment times on routing and scheduling decisions, independent of other complicating factors in the HHNRS problem. The costs of offering fixed appointment times are quantified, and purely distance-based heuristics are shown to have potential limitations for appointment time problems unless proposed arc cost transformations are used. Building on this result, a new rolling horizon capacity-based heuristic is developed for HHNRS problems. The heuristic considers interactions between travel times, service times, and the fixed appointment time menu when inserting appointments for currently revealed patient requests into partial nurse schedules. The heuristic is shown to outperform a distance-based heuristic on metrics which emphasize meeting as much patient demand as possible. The home health nurse districting (HHND) problem is a tactical planning problem which influences HHNRS problem solution quality. A set of geographic zones must be partitioned into districts to be served by home health nurses, such that workload is balanced across districts and nurse travel is minimized. A set partitioning model for HHND is formulated and a column generation heuristic is developed which integrates ideas from optimization and local search. Methods for estimating district travel and workload are developed and implemented within the heuristic, which outperforms local search on test instances.

Huvudsyftet med vår studie är att undersöka och analysera hur personal i hemtjänsten upplever sin arbetssituation samt vad relationerna till arbetskamrater respektive brukare kan ha för betydelse för denna upplevelse. Vi har därför valt en kvalitativ ansats med semistrukturerade intervjuer, som bygger på intervjupersonernas egna upplevelser av sin verklighet. Vårt övergripande perspektiv på studien är socialpedagogiken. Den teoretiska ramen består sociala nätverk, samt begreppen gemenskap och tunna nätverksband. Datamaterialet som insamlats har kodats, kategoriserats, tematiserats och analyserats i förhållande till tidigare forskning och de teoretiska perspektiven. Vår studies resultat pekar på att personalen inom hemtjänsten upplever att de har ett bra och givande arbete, där kontakten med brukarna upplevs som mycket positiv och som själva anledningen att gå till arbetet. Personalen beskriver även att arbetsgruppen har stor betydelse och att det är till sina arbetskamrater som de vänder sig för att få stöd. Studiens resultat visar tydligt att relationerna är viktiga för individens uppfattning av sin arbetssituation. / The main purpose with our study is to examine and analyze how staff in home care services perceive their work situation as well as in what way relations with colleagues or clients may have an impact on this experience. We have chosen a qualitative approach with semi-structured interviews, which builds on the experience of the interviewed individuals. Our main perspective in this study is the social pedagogy. The theoretical frame consists of social networks and the concepts community and thin networks. The collected data has been coded, categorized, thematised and analyzed in relation to former research and the theoretical perspectives. Our study results indicates that the personnel in home care services feels that they have a good and rewarding work. The contact with the users is experienced as very positive and as the main reason for them to go to work. The personnel also describe the working group as very important and it is to the colleagues they turn to get support. The result of this study clearly shows that relations are of great importance for the individuals understanding of their work situation.

Actualmente es posible el alta precoz del prematuro si va acompañada de atención domiciliaria. Nuestro PROPÓSITO es demostrar que la Atención Domiciliaria de Enfermería (ADE) del prematuro, tras su alta precoz, es beneficiosa y segura. OBJETIVOS. Comparar, en los casos y controles, la evolución del peso desde una semana prealta (de los casos), durante la ADE y al finalizarla, analizando sus posibles causas, y la morbilidad. METODOLOGÍA. Estudio caso-control (1:1), observacional y preferentemente prospectivo, de los recién nacidos del Hospital Clínic de Barcelona durante los años 2007 a 2009, prematuros (edad gestacional entre 25-36 semanas), de procedencia interna, con peso de nacimiento superior a 750 g, que cumplían las siguientes condiciones en el momento del alta (o apareamiento de los controles): ausencia de cromosomopatías o malformaciones mayores, edad postmenstrual corregida ³ 30 semanas, estabilidad térmica, alimentación por boca sin dificultad, peso superior a 1500 g e inferior a 2100 g con curva ascendente, buen estado clínico y consentimiento familiar. Se incluyeron 65 casos y 65 controles. La ADE fue administrada por un pediatra neonatólogo y dos enfermeras especializadas en neonatología, dependientes del Hospital. El programa se inició con una sesión de educación sanitaria a los padres de los prematuros tributarios de ADE. Tras el alta, la ENFERMERA realizó la primera visita en los dos días siguientes y las consecutivas dos veces por semana hasta los 2100 g. Se desplazó al domicilio en taxi. Controló el estado general, incremento de peso, alimentación, temperatura, deposiciones, medidas higiénicas, ritmo de sueño, cuidados especiales y cualquier aspecto que preocupara a la familia. Completó la educación sanitaria, comprobó la situación familiar y coordinó los horarios de las siguientes visitas domiciliarias y en el hospital. Los PADRES dispusieron de contacto telefónico con el hospital mediante el teléfono móvil asignado, visita pediátrica el día del alta y reingreso en el Hospital si fuese necesario. El/la PEDIATRA coordinador/a del programa, el día del alta realizó la visita médica y redactó un informe final complementario del alta hospitalaria. RESULTADOS. El apareamiento fue satisfactorio. En el período neonatal destacó una menor utilización de corticoides prenatales en los casos. Los prematuros de ambos grupos no estuvieron muy enfermos. La estancia total del grupo con ADE fue 10 días inferior. Las familias del grupo con ADE fueron de un nivel social superior con más trabajo por cuenta propia y estuvieron más adaptadas. Tanto los pesos de la semana previa al alta como los pesos iniciales fueron similares en los casos y controles, condición indispensable. Respecto a los cambios de peso en g/kg/día en la semana previa al alta y en la semana del estudio, los casos partieron de una cifra similar a los controles, pero terminaron el estudio con una cifra muy superior. En la semana previa al alta, en el grupo control se seguía con nutrición por sonda nasogástrica, mientras que en el grupo de ADE se retiraba antes, para facilitar su ida a casa. Durante el periodo de estudio, los casos recibieron más lactancia materna. El estudio multivariante demostró que el “incremento en g/kg/d durante el estudio” aumentaba al estar en casa (ADE) o en los varones y disminuía al recibir lactancia materna o presentar hemorragia peri-intraventricular. Durante la ADE no hubo mayor morbilidad en los casos. Sólo un 9% de las familias llamaron por teléfono. El total de visitas a domicilio osciló entre 3 y 5. Las principales incidencias fueron infecciones respiratorias. CONCLUSIÓN. La ADE es segura e implica un mayor aumento de peso del prematuro, siendo los factores que lo favorecen la ADE, la lactancia artificial, la ausencia de hemorragia peri-intraventricular y el sexo masculino. / INFLUENCE OF NURSING HOME CARE IN THE EVOLUTION OF PREMATURE INFANTS WITH EARLY DISCHARGE The purpose is to demonstrate that the Nursing Home Care (NHC) of premature infants with early discharge is safe and beneficial. OBJECTIVES: To compare the evolution of weight, analyzing their causes, and morbidity in cases and controls. METHODOLOGY: Case-control (1:1) and observational study, preferably prospective, of newborns at the Hospital Clínic of Barcelona during the years 2007 to 2009, premature, with birth weight over 750 g, which at discharge (or matching of controls) had: corrected postmenstrual age <30 weeks, thermal stability, food by mouth, weight over 1500 g and below 2100 g with upward curve, good clinical evolution and family consent obtained. 65 cases and 65 controls were included. The NHC was administered by a neonatologist pediatrician and two nurses in neonatology, dependent on the Hospital. The nurse made the first visit in two days after discharge, and afterwards twice weekly until 2100 g, by taxi. She supervised the general state, weight gain, food tolerance, temperature, deposition, hygiene and sleep rhythm of the infant. Parents arranged exclusive telephone contact with the hospital and readmission if necessary. The doctor performed the medical examination at the end of NHC and issued a supplemental final report. RESULTS: The total stay of NHC group was 10 days less. Families in the NHC group were of a higher social level. The initial weights were similar in both groups. Regarding changes in weight in g/kg/day in the week prior to discharge and during the week of the study, cases were based on a figure similar to controls, but ended the study with a higher figure. The multivariate analysis showed that the "increase in g/kg/d during the study" increased in NHC group or in males and decreased in case of breastfeeding or peri-intraventricular hemorrhage. During the NHC no major morbidity existed. Only 9% of families did a phone call. CONCLUSION: The NHC is safe and carries a greater weight gain, being the positive factors the NHC group, artificial feeding, the absence of peri-intraventricular hemorrhage and male sex.

Diss. (sammanfattning) Umeå : Univ., 2008. / Härtill 4 uppsatser.

Thesis (D.P.H.)--University of Michigan.