Improving the provision of medical care in the context of the implementation of new legislation on protecting the health of citizens and compulsory medical insurance, Assistant Minister of Health. The development of a medical rehabilitation system is the main direction for improving medical

Constantly improving the level of medical services provided to citizens is one of the priorities set for the ministry and the entire healthcare sector. Its representatives annually report to the government on progress achieved in this field. How is the situation really? What factors influence the quality of medical care, and what kind of measures in this direction are actually carried out by the state? We will answer these questions in this article.

Problem analysis

Today, in the medical field, there is ongoing talk and debate about whether it is wise to spend a lot of money to finance various measures to improve control and improve the quality of medical care (QMC), despite the fact that, according to statistics, such investments do not produce any special results. Direct investments also do not help – for example, in the period from 2011 to 2014. a significant infusion of funds was carried out to purchase new equipment, repair medical organizations and increase wages for employees.

However, based on Rosstat data, the number of violations in the provision of medical care to citizens not only did not decrease, but even increased (from 18% to 23%). Such figures are certainly discouraging and make us wonder whether it is worth continuing to spend money on medicine. The state government decided that it was not, and launched a large-scale reform in 2014 to optimize the healthcare system. The interim results of the transformations show that the situation has only worsened - the number of medical institutions has been steadily decreasing, and no obvious improvement in the quality of service has been observed in the remaining clinics. At the same time, funding for this area is also declining - in 2016, the growth of the healthcare budget in the Russian Federation compared to the previous year was only 4.3%, while the Russian ruble depreciated by 13% over the same period.

Factors influencing the quality of medical care

What is the reason for the current situation and why did the funding provided in no way affect the quality results? The answer lies in a detailed examination of the structure of detected defects and violations. In 2014, almost half of them (54.1%) resulted in harm to the health of patients. Among the main ones, two factors can be distinguished:

Medical errors and incompetence of doctors (73.7%).
Lack of specialists and medicines, malfunctions of medical equipment (23.6%).

Thus, it is clearly seen that the bulk of the problems lie not in a poor level of quality assessment or lack of the necessary infrastructure, but in people. More precisely, it’s all about the low qualifications of the staff and the weak organizational work of medical institutions. Therefore, to improve the quality of medical care, reforms in the personnel training system, constant professional development and provision of comfortable working conditions are needed.

In addition, one must take into account the fact that the level of the healthcare system (as, in principle, all social institutions) in Russia is very heterogeneous and highly dependent on the region. There are clinics in which the number of violations detected is very small, but such organizations make up no more than 15% of the total number. In this regard, along with some national measures, it makes sense to create regional healthcare development programs.

Ways to improve the quality of medical services

The optimal structure of the healthcare system and high efficiency of each medical organization are a necessary condition for creating an effective healthcare system. There are many approaches and opinions regarding the most optimal and suitable ways for Russia to improve the quality of medical care. Here are just a few of them:

Improving existing and developing new regulations in the medical field. There is still no law that would provide a detailed explanation of the term “quality of medical care,” and many already adopted documents function only nominally (and although responsibility for disclosing medical confidentiality seems to exist and is formally provided for, in reality it is up to the patient to defend his rights very difficult);
Increasing attention to the activities of junior and middle staff of medical institutions (nurses, orderlies, laboratory assistants, etc.). Despite the fact that they perform significant work, including ensuring the safety and high quality of medical services, and the level of patient satisfaction largely depends on them, the working conditions for such vacancies and the level of wages leave much to be desired. Because of this, no serious selection is carried out for these specialties, and people who are unsuitable for this type of activity often end up there;
Increasing attention to the activities of managers of healthcare institutions. As practice shows, people who do not have the required skills and experience are appointed to such important and responsible positions. We are talking primarily about leadership, organizational and psychological qualities, which, undoubtedly, specialists applying for high positions must possess;
The need to reform the medical personnel training system. Starting from September 2017, such an element of professional training as internship is completely abolished in medical universities. How yesterday’s graduates will be able to integrate into medical organizations, and how this will affect the clinical medical care is a big question.

One of the main tasks of healthcare is to ensure accessibility of medical care and increase the efficiency of medical services, the volumes, types and quality of which must correspond to the level of morbidity and the needs of the population, as well as the advanced achievements of medical science. If this task is fully realized, then the quality of medical care in the Russian Federation will be at the proper, high level.

State activities in this direction

According to the adopted strategy for the development of healthcare in the Russian Federation for 2015-2030, a number of activities are already being carried out to improve the IMC. For example, a three-level system for the distribution of medical capacity (expensive equipment, highly specialized specialists, etc.) has been created. It is expected that this measure will significantly increase the efficiency of the services provided, since now doctors in scarce specialties will be evenly distributed throughout all regions of the Russian Federation, and medical care will become more accessible. A program to strengthen state control over funds used within the compulsory medical insurance system is also being gradually implemented. In the near future, for these purposes, the institute of “financial and economic managers”, specialists who have received professional education in the field of health economics, will be introduced into the field of compulsory health insurance. In addition, events are annually planned and carried out aimed at improving the demographic situation in the state (close study of the problems of infant mortality and average life expectancy).

First, let's consider the concept of “medical care”, the responsibilities for its provision and the right to such assistance.

The general concept of “medical assistance to a person in a life-threatening condition” refers to therapeutic and preventive measures carried out in order to preserve the life of a wounded or sick person, as well as to quickly restore his health.

In the literature, even in regulatory documents, the concepts of “first aid”, “first aid”, and “ambulance” are often confused. It's not the same thing. These are completely different, sometimes even legally, concepts.

The following levels of medical care are distinguished:

First aid is carried out by people who do not necessarily have special medical education. Actually, it is precisely this help that will be discussed in this lecture. The first aid level does not involve the use of any special medical instruments, drugs or equipment.

First aid is provided by persons who have special training in providing medical care. These are nursing staff (paramedic, nurse) or pharmacist, pharmacist. This is their level of knowledge and skills.

First medical aid is provided by a doctor who has the necessary instruments and medications, and the volume of such assistance is regulated by the conditions of its provision, i.e. where it ends up - outside a hospital setting or in a clinic, an ambulance, or in a hospital emergency room.

Qualified medical care is provided by highly qualified doctors in multidisciplinary hospitals or trauma centers.

Specialized medical care can be provided at the highest level in specialized clinics, institutes and academies.

Improving the organization of medical care at the prehospital and hospital stages over recent years has led to significant changes in the structure of the outpatient, polyclinic and inpatient stages of providing medical care to the population.

The reform of management and financing of health care in the Russian Federation, the introduction of health insurance for citizens has placed new demands on the doctor providing primary medical care at the pre-hospital stage of treatment, regardless of the form of ownership, territorial subordination and departmental affiliation.

The system for organizing the assessment of the activities of local therapists and the conditions in which they found themselves did not contribute to the development of the local doctor as a good family doctor. When he made mistakes in diagnosis and treatment, the inspection bodies did not pay attention to the low qualifications of the doctor, but considered the main reason for his mistakes to be that he did not refer the patient for consultation with a specialist. The local therapist subsequently began to refer patients to other specialists, even in cases where he himself believed that this was not necessary. Today, a local physician is not directly responsible for the patient’s health, has no incentive to improve the quality of work and preventive measures, and does not strive to expand the range of his activities or to use resource-saving medical technologies.

The transition to family medicine is natural and very important. It should not be considered only as the most economical and rational way of organizing medical care. This is a mechanistic approach. The transition to family medicine is not only a search for the most effective and economical forms of organizing medical care, but the need for an integral vision of a person, his health and illness. General medical practice creates favorable conditions for structural and personnel changes in outpatient and inpatient healthcare. According to surveys, almost 70% of the population believe that it is necessary to develop family medicine.

A general practitioner provides personalized medical care to both individuals and their families. A clear distinction between primary and secondary levels of health care creates the best conditions for interaction between primary care physicians and specialists working in hospitals. This is one of the tasks of a general practitioner, family doctor.

A GP faces a wider range of tasks than a medical specialist. This is due, first of all, to its closer connection with the population. GPs are constantly faced with a wider range of medical and social problems than doctors of other specialties. He needs broader knowledge in the field of prevention, psychology, sociology, public health and other related disciplines.

The uniqueness of general medical (family) practice is determined by the fact that the doctor deals with diseases at an early stage of their manifestation, uses available technology in diagnosis, is responsible for the health of the attached population, ensures continuity in medical care, and his activities are preventive.

In his work, the GP makes the primary decision on all problems that are presented to him as a doctor, carries out constant monitoring of patients with chronic diseases and those in a terminal condition, is aware of his responsibility to the population and local authorities, works in collaboration with colleagues and persons of non-medical specialties .

Currently, in medical universities and institutions of postgraduate professional additional education in the specialty “General Medical Practice (Family Medicine),” 5,293 doctors have been trained in clinical residency and in various cycles of advanced training. The specialty “general medical practice” has been approved, and a network of faculties and departments of family medicine has been developed.

In more than 20 constituent entities of the Russian Federation, models of general medical practices are being developed, taking into account various organizational and legal forms of activity.

Rural medicine is of particular importance for the implementation of the institute of general (family) practice. Such experience exists in the Republic of Karelia, where the law “On General Medical (Family) Practice” was adopted and for 5 years work has been carried out on the principle of a general practitioner in two local hospitals and in 9 outpatient clinics. The work is carried out on a “team” principle - headed by a doctor, he has a rehabilitation nurse, a family nurse, a medical and social care nurse, as well as sisters who are instructors at schools for patients with bronchial asthma, diabetes mellitus, etc.

The All-Russian Association of General (Family) Practice Physicians has been created and is operating, and the professional magazine “Russian Family Doctor” is published.

At the same time, there has been no real reform of primary health care in a number of regions of the Russian Federation.

Rural medical outpatient clinics, the work of which is actually organized according to the principle of an outpatient clinic for general (family) practice, due to the absence in the nomenclature of medical institutions of such an institution as “General medical (family) practice”, do not have licenses for this type of medical activity.

The introduction of a general (family) practice physician service is hampered by the lack of implementation mechanisms in the field of reforming primary health care, and the lack of uniform approaches to this problem at the regional level.

It is necessary to develop a mechanism for the transition from foreign “pilot” projects to support the reform of primary health care at the regional level to the development of mechanisms for the gradual introduction of general medical (family) practice services throughout Russia.

The training of general practitioners should be carried out taking into account high qualification requirements, and be accompanied by the creation of additional training centers for general practitioners.

The development of primary medical care on the principle of a general practitioner is the most promising direction for Russian healthcare and will allow solving a number of problems: redistributing the volume of medical care between hospitals and outpatient clinics, directing available funds to the development of general medical (family) practice, increasing wages highly qualified specialists.

Analysis of the implementation of the industry program "General Medical (Family) Practice" showed the need to develop a systematic approach to improving the regulatory, legal, socio-economic, financial, material, technical, organizational, methodological and management mechanisms that determine the features of the organization and functioning of the general medical (family) service. practices in the structure of primary health care in Russian healthcare.

Improving the organization of medical care at the hospital stage remains one of the main tasks of healthcare. Hospital care continues to be the most resource-intensive sector of health care. The Russian Ministry of Health attaches extreme importance to this issue.

One of the main directions for increasing the efficiency of using hospital beds is the introduction of low-cost technologies and the development of hospital-substituting forms of organizing and providing medical care to the population, redistributing part of its volume from the inpatient sector to the outpatient sector.

This did not produce positive results in providing inpatient care. The increase in hospitalization continues in 2001. 22.4, in 1997 20.5 per 100 inhabitants, and mainly beds in rural areas were reduced, since this was very easy to do: hospitals are low-capacity and understaffed. The Russian Ministry of Health believes that, first of all, it is necessary to deal not with a formal reduction of the bed capacity, but with an economically justified restructuring with a differentiated approach to the introduction of beds of varying treatment intensity.

7. Medical ethics and deontology. Definition of the concept. Modern problems of medical ethics and deontology, characteristics. Hippocratic Oath, Doctor's Oath of the Republic of Belarus, Code of Medical Ethics.

10. Statistics. Definition of the concept. Types of statistics. Statistical data recording system.

11. Groups of indicators for assessing the health status of the population.

15.Unit of observation. Definition, characteristics of accounting characteristics

26. Time series, their types.

27. Time series indicators, calculation, application in medical practice.

28. Variation series, its elements, types, rules of construction.

29. Average values, types, calculation methods. Application in the work of a doctor.

30. Indicators characterizing the diversity of a trait in the population being studied.

31. Representativeness of the feature. Assessing the reliability of differences in relative and average values. The concept of Student's t test.

33. Graphic displays in statistics. Types of diagrams, rules for their construction and design.

34. Demography as a science, definition, content. The importance of demographic data for health care.

35. Population health, factors influencing public health. Health formula. Indicators characterizing public health. Analysis scheme.

36. Leading medical and social problems of population. Problems of population size and composition, mortality, fertility. Take from 37,40,43

37. Population statistics, study methods. Population censuses. Types of age structures of the population. Population size and composition, implications for healthcare

38. Population dynamics, its types.

39. Mechanical movement of the population. Study methodology. Characteristics of migration processes, their impact on population health indicators.

40. Fertility as a medical and social problem. Study methodology, indicators. Fertility levels according to WHO data. Current trends in the Republic of Belarus and in the world.

42. Population reproduction, types of reproduction. Indicators, calculation methods.

43. Mortality as a medical and social problem. Study methodology, indicators. Overall mortality levels according to WHO data. Modern tendencies. Main causes of population mortality.

44. Infant mortality as a medical and social problem. Factors determining its level. Methodology for calculating indicators, WHO assessment criteria.

45. Perinatal mortality. Methodology for calculating indicators. Causes of perinatal mortality.

46. Maternal mortality. Methodology for calculating the indicator. Level and causes of maternal mortality in the Republic of Belarus and the world.

52.Medical and social aspects of the neuropsychic health of the population. Organization of psychoneurological care.

60. Methodology for studying morbidity. 61. Methods for studying population morbidity, their comparative characteristics.

Methodology for studying general and primary morbidity

Indicators of general and primary morbidity.

63. Study of population morbidity according to special registration data (infectious and major non-epidemic diseases, hospitalized morbidity). Indicators, accounting and reporting documents.

Main indicators of “hospitalized” morbidity:

Main indicators for the analysis of morbidity with VUT.

65. Study of morbidity according to preventive examinations of the population, types of preventive examinations, procedure. Health groups. The concept of “pathological affection”.

66. Morbidity according to data on causes of death. Study methodology, indicators. Medical death certificate.

Main morbidity indicators based on causes of death:

67. Forecasting morbidity rates.

68. Disability as a medical and social problem. Definition of the concept, indicators.

Disability trends in the Republic of Belarus.

69. Mortality. Calculation method and analysis of lethality. Implications for the practical activities of doctors and healthcare organizations.

70. Standardization methods, their scientific and practical purpose. Calculation methods and analysis of standardized indicators.

72. Criteria for determining disability. The degree of expression of persistent disorders of body functions. Indicators characterizing disability.

73. Prevention, definition, principles, modern problems. Types, levels, directions of prevention.

76. Primary health care, definition of the concept, role and place in the system of medical care for the population. Main functions.

78.. Organization of medical care provided to the population on an outpatient basis. Main organizations: medical outpatient clinic, city clinic. Structure, tasks, areas of activity.

79. Nomenclature of hospital organizations. Organization of medical care in hospital settings of healthcare organizations. Indicators of provision of inpatient care.

80. Types, forms and conditions of medical care. Organization of specialized medical care, their tasks.

81. Main directions for improving inpatient and specialized care.

82. Protecting the health of women and children. Control. Medical organizations.

83. Modern problems of women's health. Organization of obstetric and gynecological care.

84. Organization of medical and preventive care for children. Leading problems in children's health.

85. Organization of health care for the rural population, basic principles of providing medical care to rural residents. Stages of organization.

Stage II – territorial medical association (TMO).

Stage III – regional hospital and regional medical institutions.

86. City clinic, structure, tasks, management. Key performance indicators of the clinic.

Key performance indicators of the clinic.

87. Precinct-territorial principle of organizing outpatient care for the population. Types of plots.

88. Territorial therapeutic area. Standards. Contents of the work of a local therapist.

89. Office of infectious diseases of the clinic. Sections and methods of work of a doctor in the office of infectious diseases.

90. Preventive work of the clinic. Prevention department of the clinic. Organization of preventive examinations.

91. Dispensary method in the work of the clinic, its elements. Control card of dispensary observation, information reflected in it.

1st stage. Registration, examination of the population and selection of contingents for registration at the dispensary.

2nd stage. Dynamic monitoring of the health status of those being examined and carrying out preventive and therapeutic measures.

3rd stage. Annual analysis of the state of dispensary work in hospitals, assessment of its effectiveness and development of measures to improve it (see Question 51).

96. Department of medical rehabilitation of the clinic. Structure, tasks. The procedure for referral to the medical rehabilitation department.

97. Children's clinic, structure, tasks, sections of work.

98. Features of providing medical care to children on an outpatient basis

99. The main sections of the work of a local pediatrician. Contents of treatment and preventive work. Communication in work with other treatment and prevention organizations. Documentation.

100. Contents of preventive work of a local pediatrician. Organization of nursing care for newborns.

101. Comprehensive assessment of the health status of children. Medical examinations. Health groups. Medical examination of healthy and sick children

Section 1. Information about the divisions and installations of the treatment and preventive organization.

Section 2. Staff of the treatment and prevention organization at the end of the reporting year.

Section 3. Work of doctors of the clinic (outpatient clinic), dispensary, consultations.

Section 4. Preventive medical examinations and work of dental (dental) and surgical offices of a medical and preventive organization.

Section 5. Work of medical and auxiliary departments (offices).

Section 6. Operation of diagnostic departments.

Section I. Activities of the antenatal clinic.

The main directions for improving inpatient medical care:

a) intensification of the treatment process

b) repurposing hospitals and departments (restructuring) for short- and long-term stays, varying intensity of the treatment and diagnostic process, preserving unloaded departments of city clinical hospitals (taking into account tasks for peacetime emergencies) with the creation of:

1) hospitals, departments, intensive care wards for the correction of emergency conditions and

treating patients for a limited period (no more than 5–6 days)

2) hospitals, departments, wards for follow-up treatment (after completion of the acute period of the disease);

3) medical rehabilitation units at the outpatient, inpatient and sanatorium stages (for the restoration of life limitations resulting from illnesses and injuries in persons with a certain rehabilitation potential).

4) hospitals, departments, wards of medical and social care (mainly to solve social problems, life situations, improve the health of elderly patients)

c) increasing the responsibility and economic independence of hospitals

d) ensure the development of a network of day hospitals in hospitals

e) standardize medical care (by creating diagnostic and treatment protocols, etc.)

The main directions for improving specialized care in the Republic of Belarus:

a) restructuring of the bed stock - ensuring a rational number and ratio of beds according to the level of intensity of the treatment process (rehabilitation beds, beds for long-term stay of chronic patients, beds for medical care).

b) concentration of emergency medical services and high medical technologies through the creation of specialized centers

c) ensuring a clear organizational structure of each specialized service

d) development and revision of basic protocols for the diagnosis and treatment of diseases

e) development of a state program for the development of specialized medical care

82. Protecting the health of women and children. Control. Medical organizations.

Maternal and Child Health (MCC)- a set of socio-economic and therapeutic and preventive measures aimed at optimizing the family’s lifestyle, strengthening the health of women and children and allowing a woman to combine motherhood with participation in the social and industrial life of the country.

Legislative acts regulating OMD:

a) Constitution of the Republic of Belarus - 2 articles: 32 art. - marriage, family, motherhood, fatherhood and childhood are under state protection; 45 art. - these groups are guaranteed the right to health care

b) law on the rights of the child (1993). Child - a person under 18 years of age inclusive.

c) Law on Health Care (2002), section “Protection of motherhood and childhood”.

d) labor legislation.

Stages of organization and medical institutions of OMD:

I. Providing assistance to women before pregnancy, preparation for motherhood, family planning (antenatal clinic, Marriage and Family consultation, medical and genetic consultations)

II. Activities for antenatal fetal care (antenatal clinics, children's and adult clinics)

III. Intranatal fetal care and rational management of childbirth (maternity hospital)

IV. Newborn health care (maternity hospital, children's clinic, hospital)

V. Health protection of preschool children (children's clinics, hospitals, kindergartens, schools)

VI. Health protection for school-age children

Sections of OMD: obstetric and gynecological care and therapeutic and preventive care for children.

Management of the Maternal and Child Health Service:

1. At the republican level: Ministry of Health → medical care department → department of medical care for mothers and children → 2 full-time specialists: chief obstetrician-gynecologist and chief pediatrician of the republic

2. Regional level: ZO management under the regional executive committee → 2 full-time specialists (chief obstetrician-gynecologist and chief pediatrician of the region)

3. District level: Central district hospital → chief physician.

Depending on the size of the area, specialists: if more than 70 thousand, the position of deputy chief physician of the Central District Hospital for obstetrics and childhood is introduced, and the head of the obstetrics and gynecology department serves as the chief obstetrician-gynecologist and chief pediatrician of the district; if less than 70 thousand there is a full-time position of the chief pediatrician of the district, and the chief obstetrician-gynecologist of the district is the head of the obstetrics and gynecology department.

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Ministry of Education and Science of the Russian Federation

Federal State Budgetary Educational Institution

Higher professional education

"Novgorod State University named after Yaroslav the Wise"

Multidisciplinary College

Medical College

COURSE WORK

Development of a medical rehabilitation system is the main direction of improving medical care to the population

Performed:

Student of group 16111

Bardukova A.V.

Checked:

Lisitsin V.I.

Veliky Novgorod 2015

Introduction

1. Theoretical aspects of medical rehabilitation

1.1 Medical aspect of rehabilitation

1.2 Psychological aspect of rehabilitation

1.3 Professional aspect of rehabilitation

2. Organization of medical care at the present stage

2.1 Improving the organization of medical care at the prehospital and hospital stages

2.2 Improving the organization of high-tech types of medical care

2.3 Improving the organization of medical care for war veterans

Conclusion

Bibliography

Introduction

Medical assistance is provided to the population in case of diseases, as well as in order to prevent diseases by carrying out appropriate preventive, sanitary, hygienic and anti-epidemic measures.

Medical care also includes rehabilitation. The definition of the concept of “rehabilitation” was given by the legislator in the Federal Law of November 24, 1995 No. 181-FZ “On the social protection of disabled people in the Russian Federation” as a system and process of full or partial restoration of the abilities of disabled people for everyday, social and professional activities. Rehabilitation is aimed at eliminating or possibly more fully compensating for life limitations caused by health problems with persistent impairment of body functions, for the purpose of social adaptation of disabled people, their achievement of financial independence and their integration into society.

From the first half of the twentieth century to the present, Russia has been implementing a two-level principle of building a system of medical care for the population, represented by self-sufficient and poorly integrated structures: outpatient, emergency and inpatient.

Currently, medical care is provided to the population of the Russian Federation in 9,620 healthcare institutions, including 5,285 hospitals, 1,152 dispensaries, 2,350 independent outpatient clinics, and 833 independent dental clinics.

Primary health care is a set of medical, social, sanitary and hygienic measures that provide health improvement, prevention of non-communicable and infectious diseases, treatment and rehabilitation of the population. Primary health care represents the first stage of the continuous process of protecting public health, which dictates the need for it to be as close as possible to the place where people live and work. The main principle of its organization is territorial and local.

Despite the developed network of outpatient clinics, the existing primary health care system is not able to meet the needs of the country's population and modern society.

The object of study is all types of population.

The subject of the research is the main direction of improving medical care to the population.

The purpose of the work is to study the main direction of improving medical care to the population.

1. Theoretical aspectsmedical rehabilitation

1.1 Medical aspect of rehabilitation

The desire to restore the patient’s health and ability to work is unthinkable without a fight to preserve his life.

It is not difficult to imagine that late provision of medical care, including hospitalization, leads to all sorts of complications, i.e. aggravates the course of the disease. It has been established that the fewer serious complications and the more benign the course of the disease, the more patients return to work in a shorter time. Therefore, prevention of complications, timely and correct treatment are crucial in the effectiveness of rehabilitation measures.

The medical aspect of rehabilitation is the restoration of the patient’s health through the integrated use of various means aimed at maximizing the restoration of impaired physiological functions of the body, and if this cannot be achieved, the development of compensatory and replacement functions.

Medical rehabilitation includes conservative and surgical treatment, drug therapy, nutritional therapy, climate and balneotherapy, physical therapy, physiotherapy and other methods that are used on an inpatient and (or) outpatient basis. Medical measures are certainly included in the complex of rehabilitation measures, but they are far from being uniform in order to fully solve the tasks assigned to rehabilitation. It is believed that the rehabilitation direction in medicine began to develop recently, from the late 60s of the 20th century, and was first considered as a component of the healing process. However, it seems more logical both in content and form to consider the opposite opinion - treatment is a component of rehabilitation.

Federal Law No. 323-FZ of November 21, 2011 “On the fundamentals of protecting the health of citizens in the Russian Federation” (hereinafter referred to as the Law on Health Protection), which entered into force on January 1, 2012, pays attention to many aspects of the health care system that have not been regulated in the previously existing basic regulatory legal act in this area. These include issues of medical rehabilitation. For the first time, a definition of the concept of “medical rehabilitation” has been established at the legal level and an attempt has been made to determine its place in the system of medical care.

Article 40 of the Health Protection Law states that rehabilitation is carried out in medical organizations and includes the comprehensive use of natural healing factors, medicinal, non-drug therapy and other methods. It seems important to distinguish between the concepts of “medical rehabilitation” and “sanatorium-resort treatment”.

1.2 Psychological aspect of rehabilitation

The psychological aspect of rehabilitation is the correction of the patient’s mental state, as well as the formation of his rational attitude to treatment, medical recommendations, and the implementation of rehabilitation measures. It is necessary to create conditions for the patient’s psychological adaptation to the life situation that has changed as a result of the disease.

The effectiveness of rehabilitation programs largely depends on the person’s reaction to the disease, on the premorbid characteristics of the individual, and on his defense mechanisms.

It is extremely important to assess the psychological status of the individual, which makes it possible to identify patients who are especially in need of long-term courses of psychotherapeutic measures aimed at relieving anxiety, neurotic reactions, and developing an adequate attitude towards the disease and recovery measures. The nature of the manifestations and course of the disease are associated with personality traits and the characteristics of the socio-psychological situation in which the person finds himself. The development of various health disorders depends on the nature and intensity of emotional stress experienced by a person.

An important goal of psychological assistance to people with disabilities is to teach the patient to independently solve the problems facing him in relation to professional activities and family life, focusing on returning to work and, in general, to active life.

For the purpose of secondary prevention of functional disorders during psychological rehabilitation, special attention must be paid to persons whose personality traits are a psychological risk factor (the so-called type “a”, which is characterized by such traits as the desire for leadership, competition, self-dissatisfaction, inability to relax, feverish preoccupation with work, etc.). Effective psychological rehabilitation of disabled people leads to the formation of an adequate assessment of their capabilities, a strong work orientation, and the disappearance of “rental” attitudes (caused, as a rule, by ignorance of their capabilities and inability to adapt to new living conditions).

To date, neither theoretically nor practically, solutions have been found to the issues of psychology of social partnership in the field of rehabilitation of disabled people. This partnership is of particular importance when choosing and implementing social rehabilitation measures.

Social rehabilitation measures cover almost all issues of life of disabled people and include social, social, legal and socio-psychological rehabilitation. The leading areas of social rehabilitation are considered to be medical and social care, pensions, benefits, and provision of technical equipment.

1.3 Professional aspecthabilitation

The professional aspect of rehabilitation is resolving issues of employment, vocational training and retraining, and determining the working capacity of patients. This type of rehabilitation involves the restoration of theoretical knowledge and practical skills in the main specialty to the level of knowledge and skills necessary to perform professional activities in a previously acquired specialty at the appropriate level.

The socio-economic aspect of rehabilitation is the return of economic independence and social usefulness to the victim. This is the restoration, and if impossible, the creation of a new position acceptable for a particular person in a family, team or in a larger society. The above problems are solved not only by medical institutions, but also by social security authorities. Therefore, rehabilitation is a multifaceted process of restoring a person’s health and reintegrating him into work and social life. It is important to consider all types of rehabilitation in unity and interconnection. At the same time, in our country and practically throughout the world there is no single service that would ensure the complexity and effectiveness of rehabilitation.

Initially, rehabilitation was identified with the restoration of working capacity, which, in turn, is a criterion for the effectiveness of rehabilitation. The professional aspect of rehabilitation is broader. This is not just restoration of ability to work, but restoration of professional activity.

The professional aspect of rehabilitation should be considered from the point of view of not only the restoration of lost ability to work, but also the further prevention of its possible decline. Successful restoration and preservation of working capacity is a product of many factors: proper examination of working capacity, systematic secondary prevention, as well as the implementation of a program aimed at increasing the physical and mental tolerance of patients (disabled people). The report of WHO experts states that “the goal of rehabilitation is not only the desire to return the patient to his previous condition, but also to develop his physical and mental functions to an optimal level. This means restoring independence in daily life to the patient, returning him to his previous job, or, if possible, preparing the patient to perform another full-time job appropriate to his physical capabilities, or preparing him for part-time work, or for work in a special institution for the disabled."

Not only clinicians, but also specialists in related fields take part in solving these important problems: occupational hygiene, physiology and psychology of work, ergonomics, labor training and education, labor legislation, etc.

Thus, solving the problems of professional rehabilitation requires an integrated approach and a collaboration of various specialists, among whom clinicians should be the leaders. Labor activities consist of preparing disabled people for work. They should begin as early as possible and be carried out in parallel with medical, psychological and other rehabilitation measures. Even before obtaining certain production skills or retraining, a disabled person (patient) must be professionally oriented in the main specialties and know the requirements for his chosen profession. Labor (vocational) rehabilitation ends with the employment of disabled people.

In accordance with the requirements for work ability and employment, the profession must: not aggravate the severity of the general condition of the disabled person; to promote the greatest manifestations of the abilities of a disabled person; provide the disabled person with maximum satisfaction; observe the principle of matching the physical performance of a disabled person with the level of energy consumption for a given professional activity.

Occupational therapy undoubtedly contributes to the restoration of physical performance, while also having a beneficial psychological effect on the disabled person. It is no coincidence that Celje said that “idleness accelerates the onset of old age, work prolongs our youth.”

Occupational therapy changes the relationships of disabled people with other people, i.e. improves his social rehabilitation. There are functional occupational therapy, aimed at restoring impaired body functions due to illness, and industrial therapy, which prepares the patient (disabled person) for work and helps restore the professional capabilities of the disabled person. M.S. Lebedinsky and V.N. Myasishchev identifies several aspects of the therapeutic effects of labor: stimulation of life processes and increasing the body’s resistance; distraction from painful experiences; strengthening intellectual and volitional qualities in accordance with the conditions and requirements of reality; increasing the mental tone of a disabled person; freeing him from the feeling of his inferiority and inferiority; restoration of the disabled person’s connection with the team. An active lifestyle is one of the means that stimulates the mental and physical development of a person. In the process of work, the formation of a full-fledged personality occurs.

An inactive lifestyle leads to weakness and a decrease in the level of vital functions of the body. Work should bring joy, not be burdensome, not lead to fatigue, and correspond to the physical capabilities of the body.

When performing any work, high performance is not achieved immediately. This requires a certain time, the so-called work-in period. Therefore, one must enter into any work gradually, as if picking up the pace. A rapid start to work leads to premature fatigue. Constant work has a positive effect on the human body at any age.

Occupational therapy is an important factor in the system of rehabilitation measures. Indeed, often, due to somatic and mental disorders, a person is taken away from his favorite job and team for a long time, and begins to forget previously acquired work skills. In chronic diseases, idleness and separation from systematic work are the main factors that cause inertia, indifference, passivity, and withdrawal from friends. The task and purpose of occupational therapy is not to give the patient the opportunity to fall into idleness, but to establish an active attitude towards work and to re-create the stereotypes of work activity with their complex of social connections that are beginning to be lost. Purposeful work in a team helps to find a way back into the team and society. An active and varied daily routine also contributes to the fact that the motives that determine the patient’s behavior, that is, painful experiences and phenomena, fade and become less relevant.

2 . Medical organizationwhat help at the present stage

2.1 Improving the organization of medical care at dogosnursing and hospital stages

First, let's consider the concept of “medical care”, the responsibilities for its provision and the right to such assistance.

The following levels of medical care are distinguished:

Qualified medical care is provided by highly qualified doctors in multidisciplinary hospitals or trauma centers.

Specialized medical care can be provided at the highest level in specialized clinics, institutes and academies.

In more than 20 constituent entities of the Russian Federation, models of general medical practices are being developed, taking into account various organizational and legal forms of activity.

The All-Russian Association of General (Family) Practice Physicians has been created and is operating, and the professional magazine “Russian Family Doctor” is published.

At the same time, there has been no real reform of primary health care in a number of regions of the Russian Federation.

2.2 Improving the organization of high technologytechnical types of medical care

medical assistance organization

The basis for sending citizens of the Russian Federation to federally subordinated healthcare institutions subordinate to the Ministry of Health of Russia and the Russian Academy of Medical Sciences to consider the possibility of hospitalization for the provision of expensive (high-tech) medical care is: a decision of the healthcare management body of a constituent entity of the Russian Federation, the Ministry of Health of the Russian Federation, including its structural divisions - the Department of Organization and Development of Medical Care to the Population and the Department of Organization of Medical Care for Mothers and Children, the Russian Academy of Medical Sciences, including its structural unit - the Department for Regulation of Specialized Medical Care to the Population.

If there is a need to refer a patient to a federal healthcare institution subordinate to the Ministry of Health of Russia and the Russian Academy of Medical Sciences, for the provision of expensive (high-tech) medical care from a constituent entity of the Russian Federation, an appeal and a detailed extract from the medical history containing the conclusion of the corresponding chief specialist of the governing body are first sent to the head of the institution healthcare of a constituent entity of the Russian Federation, as well as data from clinical, radiological, laboratory and other studies corresponding to the profile of the disease no more than a month ago.

When referring patients to federal healthcare institutions subordinate to the Russian Academy of Medical Sciences, a copy of the appeal is sent to the Russian Academy of Medical Sciences (Department for Regulation of Specialized Medical Care to the Population).

The referral of patients to a federal healthcare institution, subordinate to the Ministry of Health of Russia and the Russian Academy of Medical Sciences, is issued by the Reception for servicing nonresident patients.

To organize medical and advisory assistance to patients in need of expensive (high-tech) medical care, a Commission is created to select patients for examination and treatment to provide expensive (high-tech) medical care.

The commission makes the final decision on further actions regarding the patient. The period for deciding whether a patient is indicated for expensive (high-tech) medical care should not exceed 14 days from the date of receipt of medical documents, and in case of a face-to-face consultation - no more than 7 days.

Sends the decision of the Commission to the head of the healthcare management body of the constituent entity of the Russian Federation, indicating the approximate time frame for calling the patient for an in-person consultation and (or) hospitalization. A justified refusal to hospitalize is accompanied by detailed recommendations for further tactics of patient management.

If there is a waiting list for hospitalization, he enters information about patients awaiting hospitalization to provide expensive (high-tech) medical care.”

2.3 Improving the organizationmedical assistance to war veterans

Every year there is a decrease in the number of disabled people and participants in the Great Patriotic War (mainly due to those who died from natural causes of death, due to their advanced age). The main causes of death among combatants are unnatural: injuries, poisoning, murder and suicide.

One of the primary tasks to improve the socio-economic living conditions of war veterans is the creation of their name Register, the medical part of which (data bank on wounds received, injuries, diseases, treatment provided and current state of health) should be formed and permanently located only in medical -preventive institutions, taking into account the confidentiality of this information.

Not the least role in the creation of the Register should be played by public organizations and associations of veterans, since the effectiveness of measures aimed at preserving the and promoting the health of these populations.

It is active clinical observation, regular planned treatment and medical rehabilitation that make it possible to ensure active longevity of this contingent (mortality in general in the age group of 70 years and older ranges from 8 to 20%).

In accordance with the Program of State Guarantees for Providing Citizens with Free Medical Care, approved by the Government of the Russian Federation, all veterans are provided with emergency, inpatient and outpatient care, including annual medical examinations, at the expense of budgets of all levels and compulsory medical insurance, as well as preferential drug provision and prosthetics (dental, eye and hearing prosthetics).

Medical care for war veterans and disabled people in all medical institutions of the Russian Federation, regardless of departmental affiliation, is provided on a priority basis: priority appointments in clinics and extraordinary planned hospitalization for inpatient treatment. There are no significant problems in the implementation of this benefit established by the Federal Law “On Veterans”, since it does not require the allocation of additional financial resources from budgets.

Hospital institutions focused primarily on providing routine inpatient care to veterans are 61 war veterans' hospitals located in 54 constituent entities of the Russian Federation. Their dispensary observation and medical rehabilitation are also carried out here. In 2002 alone, 3 hospitals for war veterans were opened in the Primorsky Territory, Tambov and Bryansk regions.

There are no refusals of inpatient treatment in medical institutions that do not have departments or wards for war veterans, and hospitalization of veterans is carried out on a priority basis. Outpatient services for veterans are also provided out-of-turn.

According to annual examinations, more than a third of participants and almost half of war invalids require hospital treatment.

Taking into account the advanced age of veterans of the Great Patriotic War, gerontological centers were created on the basis of many hospitals, the main function of which is organizational and methodological assistance to all medical and preventive institutions of the subject of the federation in providing geriatric care to elderly and senile people. Some of them (in Yaroslavl, Samara, Ulyanovsk and other cities) have the status of international centers for the problems of the elderly.

In many hospitals, medical and social expert commissions constantly operate; some establish or change the disability group for veterans, associate disability with being at the front, determine indications for the provision of motor transport, and the need for outside care already during the period of treatment in the hospital.

It is war veterans' hospitals that work most closely with veterans' organizations on solving a number of medical and medical-social problems of veterans. Representatives of veterans' associations are on the boards of trustees of these medical institutions and actively contribute to attracting extra-budgetary funds to improve the material and technical base of hospitals, supplying them with medicines and food.

Thanks to the active work of public associations of veterans, issues of medical care for these contingents, including drug provision and various types of prosthetics, are regularly considered at the boards of territorial health authorities.

One of the urgent tasks today is the creation of an effective interdepartmental system of medical and medical-social rehabilitation of combatants. A working meeting of heads of hospitals for war veterans and military medical institutions of various departmental affiliations was devoted to discussing the organizational and methodological aspects of creating in the Russian Federation a unified interdepartmental system of medical and social rehabilitation of participants in combat operations and counter-terrorism operations, family members of fallen military personnel and law enforcement officers.

Since diagnosis and treatment of the consequences of “combat trauma” are today carried out both in hospitals for war veterans and in institutions of the general medical network, the main attention at the meeting was paid to the issues of medical rehabilitation of combatants.

In 1989, 3 rehabilitation centers for “internationalist warriors” with a capacity of about 1000 beds were created in the Russian Federation: “Rus” in the Moscow region, “Baikal” in the Irkutsk region and “Anapa” in the Krasnodar region, financed from the federal budget.C 1994 “Baikal” and “Anapa” ceased to function as rehabilitation treatment centers. The rehabilitation center "Rus" was transferred to the All-Russian public organization of disabled people from the war in Afghanistan. Disabled “Afghans” and family members of the victims undergo medical rehabilitation there at the expense of federal budget funds allocated to the Ministry of Labor and Social Development of the Russian Federation for sanatorium and resort treatment of disabled people.

Serious difficulties have arisen in carrying out medical rehabilitation of “internationalist soldiers” on the ground, since there are only a few specialized medical institutions in the country that provide comprehensive diagnostic and treatment, advisory, medical and social care, and dispensary observation only for this contingent.

However, the problem of limited availability of medical rehabilitation assistance to combatants is not only in a small number of specialized centers, but also in the absence of a clear system of interdepartmental interaction and continuity in resolving these issues.

Medical and preventive institutions operate as a unified system of phased medical rehabilitation, including all organizational links in the provision of medical care (polyclinic, hospital, rehabilitation and sanatorium-resort treatment institutions). St. Petersburg and Moscow, Volgograd, Nizhny Novgorod, Omsk, Rostov, Ryazan and other regions. In many cases, this system operates as an interdepartmental one and includes structural units of social protection, employment services, etc.

At the same time, the main link of this system, as a rule, is hospitals for war veterans. The centers or separate units of medical rehabilitation created within their structure need not only to be re-equipped with other medical equipment, taking into account the changing structure of morbidity and disability among younger populations, but also to introduce new treatment and rehabilitation techniques and retraining of personnel.

Some of the upcoming tasks can be solved by developing and implementing an appropriate federal target program. Another part of the tasks of ensuring the current activities of such an interdepartmental structure can be solved only by determining the target source of current funding.

One of the targeted sources of funding for medical and medical-psychological rehabilitation of military personnel and law enforcement officers who have received “combat trauma,” including post-traumatic stress disorder, may be funds from “additional” state medical insurance, covering only contingents sent to “hot” spots .

Accumulating these funds in the state medical insurance fund or the corresponding military insurance medical company (uniform for all “power” structures or in each of them), providing such insurance policies to combatants will allow them to receive the necessary rehabilitation measures in medical organizations and institutions, regardless on their departmental affiliation and organizational and legal form.

A possible mechanism for optimizing the functioning of the interdepartmental rehabilitation system and its effective management would be the creation of coordination councils under local executive authorities, which would include heads of territorial health authorities, social protection, compulsory health and social insurance funds, employment services, education, as well as "power" ministries and departments, public organizations of veterans, etc.

The creation of similar coordinating bodies in the federal districts and at the federal level, to which authorized military insurance medical companies and funds would be accountable on these issues, would make the system of state guarantees for the protection and restoration of the health of military personnel and law enforcement officers truly effective.

Conclusion

One of the main factors in creating a system of high-quality and accessible medical care is the presence of uniform procedures and standards for the provision of medical care for the most common and socially significant diseases and pathological conditions throughout the entire territory of the Russian Federation.

Standards of medical care are developed in accordance with the indicators of the State Guarantees Program, and their implementation is guaranteed to citizens throughout the Russian Federation.

The creation of standards of medical care will make it possible to calculate the real cost of medical services in each subject of the Russian Federation, determine the costs of implementing state and territorial programs of medical care to the population, calculate the necessary drug supply for these programs (list of vital and essential drugs), justify per capita financing standards and optimize options for restructuring the network of healthcare institutions.

The introduction of procedures for the provision of medical care will make it possible to optimize its phasing, use the correct algorithm for interaction between healthcare and social security institutions, and ensure continuity in the management of the patient at all stages, which will significantly improve the quality of medical care to the population.

Procedures and standards for the provision of certain types of medical care form the basis of the program of state guarantees for the provision of free medical care to citizens, corresponding to the modern level of development of medicine and mandatory for implementation.

One of the main elements of quality assurance should be considered the development by professional communities (associations) of clinical recommendations (guidelines) containing information on the prevention, diagnosis, treatment of specific diseases and syndromes, which will serve as the basis for the development of standards of medical care, indicators of the quality of the diagnostic and treatment process.

Today there is no coherent system of restorative treatment and rehabilitation in the country. In many cases, the patient is discharged from the hospital “under the supervision of a local doctor,” which in reality means “under his own supervision.” At the outpatient clinic level, the patronage service is poorly developed, the “hospital at home” system has not been developed, continuity of treatment between the hospital and the clinic is often not ensured, and rehabilitation measures are not available to patients.

The currently existing departments (offices) for restorative treatment and rehabilitation do not meet modern requirements for equipping with diagnostic and therapeutic equipment. There is an acute shortage of specialized personnel in the rehabilitation service (doctors and exercise therapy instructors, physiotherapists, speech therapists, neuropsychologists, medical psychologists, occupational therapists, social workers, etc.). The necessary regulatory framework for the process of restorative treatment and rehabilitation is completely absent.

Thus, the existing needs of a significant part of the population of the Russian Federation for restorative treatment and rehabilitation are also not met.

The current situation in healthcare requires deep reforms in the field of human resource management in the industry.

The goal of the personnel policy is the training and retraining of specialists who have modern knowledge and are able to ensure the economic and clinical effectiveness of the high medical technologies used and new methods of prevention, diagnosis and treatment, achieving an optimal ratio of the number of doctors and nursing staff, as well as eliminating imbalances in the staffing of all levels of the health care system.

The organization of personnel policy must be consistent with educational policy in the system of continuing professional education, and also aimed at stimulating the motivation of medical workers to improve their professional qualifications.

Bibliography

1. Federal portal PROTOWN.RU

2. Order of the Ministry of Health and Social Development of the Russian Federation No. 192 of the Russian Academy of Medical Sciences No. 67 dated November 10, 2004.

3. Order of the Ministry of Health of the Russian Federation and the Russian Academy of Medical Sciences dated July 10, 2000 No. 252.50 “On the organization of the provision of high-tech (expensive) types of medical care in healthcare institutions of federal subordination”

4. Vasily Bogolyubov “Medical rehabilitation” book 1. pp. 5-6, 23.

5. L.F. Gaidarov, G.Yu. Lazareva, V.V. Leonkin, E.A. Mullayarova, E.V. Sitkalieva, M.V. Sokolova “Handbook for rehabilitation after illness” 1-2

6. Dmitry Viktorovich Sharov, Sergey Alexandrovich Ivanyuk “Rehabilitation after fractures and injuries”

7. http/Medli.ru

8. Urs Buman, Mainrad Perret “Clinical Psychology”. 60-61

9. Grigorieva M.V. “Work Psychology” 20

10. Order No. 529 of April 16, 2009 On establishing the procedure for extraordinary provision of medical care to certain categories of citizens who have benefits in accordance with the Federal Law “On Veterans”

11. Order No. 5 01/13/2010 On conducting in-depth medical examinations of veterans of the Great Patriotic War.

12. Appendix No. 1. “Information from an organization providing medical care services to the population.”

13. Medical encyclopedia.

14. http://www.medical-enc.ru/

15. Kremlin medicine clinical bulletin Acting Editor-in-Chief Ph.D. I.A. Egorova s. 9.24

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Improving the provision of medical care in the context of the implementation of new legislation on protecting the health of citizens and compulsory medical insurance, Assistant Minister of Health. The development of a medical rehabilitation system is the main direction for improving medical

Problem analysis

Factors influencing the quality of medical care

Ways to improve the quality of medical services

State activities in this direction

82. Protecting the health of women and children. Control. Medical organizations.

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