出院準備連結長照中心之服務模式－以高雄縣某區域醫院爲例

The Service Model of Connection between Discharge Planning and Long Term Care Center-An Example of Division Hospital in Kaohsiung County

紀淑靜(Shu-Ching Chi) ； 葉莉莉(Li-Ly Yeh) ； 姚美玉(Mei-Yu Yao) ； 黃志中(Joh-Jong Huang)

《長期照護雜誌》 14卷3期 (2010/12) Pp. 347-355

https://doi.org/10.6317/LTC.201012_14(3).0009

摘要

台灣現有提供長期照護評估與資源連結的服務為醫療機構之出院準備服務（簡稱出服）及各縣市長期照顧管理中心（簡稱長照中心）。本文說明高雄縣衛生局及社會處與醫院出服連結的夥伴計畫歷程與成果。此計劃目的為強化兩個服務組織的優勢，使需求長照服務甚多的病人於出院後，可快速連結社區照顧體系，落實無縫隙、連續性的照顧服務。建構歷程包含：建立合作夥伴間的共識並設定目標、確立問題、進行人員教育；改善轉介流程、整合服務與評估工具；成果顯示計劃執行可提升長照需求評估的一致性並加速資源連結時效。此計畫顯示透過醫院出服與長照中心建立夥伴關係，可落實連續性的長期照顧服務，創造民眾、醫院及政府三贏的局面。

關鍵字

出院準備服務 ； 長期照顧管理中心 ； 夥伴關係

並列摘要

Discharge planning and long term care center are two kinds of service provide long term care needs assessment and service referral. This article describes the process and outcomes of Kaohsiung County's health and welfare department connect with discharge planning to fulfill people's long term care needs. In the project, we build program objective, identify problems and provide staff education, change referral process, integrate service and assessment tool. Outcome: Increase the agreement of service need assessment and shorten the time needed to gain the referral service. The program demonstrated that partnership between discharge planning and long term care center did enhance continuity of care of those who need long term care service.

並列關鍵字

discharge planning ； long term care center ； partnership