At present, observational studies and expert opinion are the best evidence for the use of physical restraints. Large regional and national disparities are described in acute and long-term care. Epidemiological data demonstrate a prevalence of 3-5% body-fixed or near body restraint devices. The hip fracture rate in Germany are approximately 50 per 1000 resident years. Between 40-50% of the residents in nursing homes are treated with psycho-tropic medication potentially limiting their physical mobility. The presented study protocol was designed to test the effectiveness of a multifactorial intervention to reduce physical restraints in long-term care (LTC) residents particularly with cognitive impairment. The intervention consists of an educational and an organizational part to empower staff members to improve their skills and practice in using restraints. Technical devices to reduce fall related injuries are additionally offered to the LTC facilities. The study population includes 200 LTC residents in 54 facilities in three states in Germany. The sample size calculation was based upon a 5% prevalence rate in the control group and an expected reduction of 50% in the intervention group. The protocol is a waiting-list control design. All waiting facilities will be offered to participate after their waiting period. Primary endpoints are the number of restrained residents and resident time (hours) of being restrained. The use of psychotropics, falls, fall-related injuries and the incidence of residents newly being restrained is being monitored. The study starts with a baseline documentation of all facilities followed by randomization and a three month intervention. Change agents will be responsible for the intervention. Technical devices will include a newly developed soft hip protector and sensor mats which notice the intent of leaving the bed. The aim of the study is to develop an evidence-based model for a knowledge transfer project to implement minimum restraint environments in LTC.
Zusammenfassung
Die gesetzliche Pflegeversicherung als individuelle Teilkaskoversicherung des Risikos der Hilfe- und Pflegebedürftigkeit hat sich seit der Einführung 1995 als staatlicher Beitrag zur Stärkung und Sicherung der familiären Unterstützungsleistungen verstanden. In den letzten 25 Jahren hat das System eine deutliche Ausweitung erfahren und ist inzwischen zum dominanten Sicherungssystem der Unterstützung und Hilfen im Alter geworden. Angesichts des demografischen und soziostrukturellen Wandels und der damit verbundenen steigenden Bedarfe wurde und wird die Pflegeversicherung kritisiert, mit dem wachsenden Bedarf nicht schritthalten zu können. Insbesondere die aktuelle Kritik sieht im Fachkräftemangel und den steigenden privaten Kosten der Pflege ein Versagen des Marktprinzips der Pflegeversicherung. Gefordert werden eine bessere Gesamtkoordination der sozialen Leistungen im Alter und ein stärkerer Einfluss der Kommunen. Der Beitrag analysiert die bisherigen Entwicklungen, zeigt verpasste Chancen auf und spricht sich für eine stärkere Sozialraumorientierung und kommunale Koordination aus.
In times of demographic and social change, it is increasingly important to ensure the availability of care services to cover the growing demand. With the implementation of the German long-term insurance act in 1994, the responsibility of states and municipalities was maintained; however, given the long-term care legislation's market orientation and competition neutrality, the classic instruments for demand planning and supervision of infrastructure developments were lost. This leads to new challenges for states and municipalities: their conventional objective-oriented planning lacks professional and juridical legitimization. Calculations of requirements must relate to methodology and professional expertise. In order to exercise their influence on infrastructure development, instruments of demand planning other than subsidization are required. Using the example of Rheinland-Pfalz (Rhineland-Palatinate) and the newly implemented care structure planning, the concept of care monitoring is introduced, and instruments to influence infrastructure development are outlined.
In Germany, there clearly appears to be a gap between care carried out at home and in in-patient settings (residential nursing care). Numerous innovative projects of alternatively structured care, like for instance shared flats or group care units for people with dementia are placed in between the traditional, either home-based or institutionalised care patterns. It seems imperatively necessary to overcome the rigid separation between the inpatient sector and care carried out at home. In this article, backgrounds, necessities and perspectives of projects placed in between the traditional structures are discussed.
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