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当院は障害児・者に対する総合医療療育施設で,脳神経内科医と小児科医とで移行医療に取り組んでいる。移行チェックリストと移行カンファレンスを利用し,多職種の協力も得て,患者に適切な診療と地域医療連携,福祉サービス利用を推進している。さらに,患者・家族のセルフマネジメントの向上,患者の最善の利益を考えた協働意思決定にも努めている。近年,移行医療支援体制の中で脳神経内科医の必要性が高まっている。
Abstract
Our hospital provides medical care and rehabilitation for individuals with disabilities. In our hospital, both neurologists and pediatricians have been working on the transition from pediatric to adult healthcare. We used a transition readiness checklist and pediatrician-neurologist transition consultation. We aimed to promote appropriate medical care, community-based healthcare coordination, and welfare services through interprofessional care with other health professionals. We assisted patients and their families in improving self-management and discussed patient issues with their best interests in mind through a shared decision-making process. Recently, the need for neurologists in transitioning patients from pediatric to adult healthcare has been increasing.
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