Care Plan and Evaluation for Supporting Independence of Basic ADL in Home Care

我们于1998年至2000年进行了“家庭护理中支持基本ADL独立性的护理计划与评估”的研究。1998年，我们分析了使ADL独立的条件。结果是，在两个月内可以改善的项目是换布，药物治疗，疼痛，以及照顾者的精神和/或身体疲劳。同年，我们分析了需求或问题的解决方案，取决于是否实施护理计划和修改计划。结果，高评价的需求解决方案为(1)根据需求修改后的护理计划的实施，(2)护理计划的实施，(3)不实施。需要修改的因素依次为客户状况、服务提供状况和护理经理。1999年，我们以美国医疗保险居家照护机构强制要求的OASIS （The outcome Assessment Information Set）为中心，结合我们开发的日文版居家照护评估表，利用ADL变化结果项进行居家照护评估。在此基础上，在5个机构（走访护理站）实施护理计划。2000年，我们确定了结果项目的评估内容、依赖改变和护理过程的满意度，制定了制定计划、评估结果和实施后再计划的方法，制定了评估服务提供者能力发展和机构组织能力改善的方法，并将其手工化。此外，在客户结果方面，我们与芬兰进行了合作。

We conducted research on "Care Plan and Evaluation for Supporting Independence of Basic ADL in Home Care" from 1998 to 2000.In 1998, we analyzed conditions which enabled independence of ADL.Result was that items, which could be improved in two months, were cloth changing, medication, pain, and mental and/or physical fatigue of caregiver. In the same year, we analyzed solution of needs or problems, depending on whether or not care plan was implemented and by amending plan. As a result, the other of highly-rated need solution was (1) implementation of care plan after amending in accordance with needs, (2) imp1ementation of care plan, (3) no implementation. The order of factor for amendment was client condition, service providing condition and care manager.In 1999, we conducted home care evaluation using outcome items of ADL change, centering on OASIS (The Outcome Assessment Information Set) which was compulsory to Medicare home care agencies in U.S.A.combining with Japanese version of home care assessment sheet which we developed. Then based on these, we implemented care plan in five agencies (visiting nursing stations).In 2000, we finalized outcome items evaluated contents and satisfaction degree of dependence change and care process, developed the method to make plan and evaluate outcome and plan again after implementation, developed method to evaluate ability development of service provider and organizational ability improvement of these agencies, then manualized them.In addition, regarding client outcome, we conducted collaboration with Finland.