由社區據點發展醫院型社區整合照護

Implementation of Hospital-Based Community Integrated Care by Service Stations

李秉翰(Pin-Han Lee) ； 周倩如(Chien-Ju Chou) ； 莊茗文(Ming-Wen Zhuang) ； 楊君宜(Chun-Yi Yang) ； 黃弘孟(Hung-Meng Huang) ； 周佑珊(You-Shan Zhou) ； 盧欣宜(Hsin-Yi Lu) ； 陳重榮(Trong-Zong Chen)

《北市醫學雜誌》 16卷附冊 (2019/10) Pp. 47-59

https://doi.org/10.6200/TCMJ.201910/SP_16.0005

摘要

台灣人口老化快速，已於2018年進入「高齡社會」，台北為全國首善之區，對高齡人口成長及伴隨而來的龐大醫療、失能、長照需求問題應想出對策。面對老化趨勢，各國都希望以「整合照護」的方式來因應。然而每個國家因制度、環境、文化的差異，成效也不盡相同。在參考其他國家的照護模式後，我們於台北市中正區永昌里設置了服務據點，提供醫院型社區「整合照護」模式來滿足民眾「居家醫療」及「長期照護」的需求，實現在地社區居民「醫養結合」之理想。醫院型社區整合照護以個案為中心，結合當地民政、社政資源，深入社區、主動發掘社區中的弱勢、低收、失能、獨居、複雜需求個案，既使不符長照收案資格者也能得到照護，並且顯著降低照顧者負荷及延緩失能，降低不必要之急診使用。

關鍵字

醫院型社區整合照護 ； 居家醫療 ； 長期照護 ； 醫養結合 ； 複雜需求個案

並列摘要

Taiwan population is aging rapidly and has already officially entered the era of an aged society in 2018. Taipei, the country most populous city, is facing the growth of aging population with enormous needs in medical care, disability prevention, and long-term care. To mitigate these problems would require an urgent countermeasure. Integrated care has been globally anticipated to tackle the issues of aging population. However, the practices and effects vary from country to country due to institutional, environmental, and cultural differences. On referring to integrated care models across countries, we set up a service station at Yong Chang Village, Zhong Zheng District, Taipei and provide a hospital-based community integrated care to meet the public needs on both home medical care and long-term care, and achieve the goal of medicine and health-living as one of the community. The hospital-based community integrated care offers person-centered services. Our team members, through joint efforts with civil affairs and social affairs, take an active role in searching cases with complex needs, including the underprivileged minority, low-income households, disabled people, and elderly people living alone. With our assistance, even citizens who are not qualified for the long-term care service can gain access to the healthcare. Our interventions significantly reduce the burden of caregivers, prevent disabilities, and avoid unnecessary emergency room visits.

並列關鍵字

hospital based community integrated care ； home medical care ； long-term care ； integrates medical care and long term care ； complex need case