建構社區整合照顧模式之醫養結合

Community-Based Care Model through Healthcare and Long-Term Care Integration

翁瑞萱(Ruey-Shiuan Ueng) ； 徐愫萱(Su-Hsuan Hsu) ； 璩大成(Dachen Chu) ； 謝明軒(Ming-Hsuan Hsieh) ； 吳淑雯(Shu-Wen Wu) ； 黃肇明(Chao-Ming Huang) ； 周姚均(Yao-Chun Chou)

《北市醫學雜誌》 16卷附冊 (2019/10) Pp. 60-67

https://doi.org/10.6200/TCMJ.201910/SP_16.0006

摘要

隨著高齡化社會，老年人口遽增，長者的照顧含括的層面廣泛，為落實在地老化與在地安養，提供多樣化資源以減輕照顧者之負擔，台北市政府積極推動整合式的長照服務，北市聯醫推動醫養結合之社區整合照顧服務，此模式分三個階段建置:「建立模式」｣、「建置服務團隊」｣、「複製拓展社區整合照顧」。先以蘭州國宅為服務範圍，再將蘭州經驗拓展至其他16個據點。此模式以小區域人口數約20,000-30,000人口設置服務據點，以個案管理師為單一窗口，以居家醫療作為主軸與後盾，依據個案的需求，串連社政、衛政、民政及非政府組織等各種資源，整合醫療照護與長期照顧，提供以人為中心、醫養結合的全人照護。過程中面臨長照人才培育及留任、建置資訊平台及整合照護資訊、在地駐點、主動發掘弱勢族群及建構外展可複製之模式等挑戰。北市聯醫積極建置以人為中心、跨領域與跨專業的資訊交流平台，提升溝通效能與照護品質。期許未來持續努力透過實證方法將北市聯醫的經驗外推分享，作為長照政策推動的參考。

關鍵字

醫養結合 ； 社區整合照顧模式 ； 以人為中心照護 ； 社區據點 ； 個案管理師 ； 個案管理

並列摘要

With the population of the elderly dramatically increasing, the elderly care covers a wide range of services in this super-ageing society. In order to implement aging in place and nursing in place, a variety of resources to lessen burden on caregivers, The Taipei City government proactively promotes a community integrated care service that combines healthcare and long-term care service. Three construction phases, namely, establishment mode, build service team, and replication, and expansion of community integration care, form the care model. The project first launched at the Lanzhou Public Housing and further expanded into other 16 areas. Each station serve 20000 to 30000 residents. The care manager is the single window and the care model is supported and backed-up by the Home-based Primary Care of TCH. According the care needs of the people, the care manager links the resources of health care, social welfare, civil affairs, and non-government organization, and integrates healthcare and LTC care to provide a holistic care which is person-centered and combines healthcare and long-term careservice. During the process, we faced the challenges of nurturing and retaining long-term care human power, establishment of information platform, integrated care information, and service station, searching underprivileged population, and outreaching replicable models. We also plan to develop a person-centered information exchange platform which is interdisciplinary and inter-professional. Furthermore, we hope to share and extend our experience through the method of evidence-based research and provide the government a reference for promoting LTC policy.

並列關鍵字

Integrates healthcare and Long-term Care ； Home-centered integrated Care: HCIC ； Person-centered care ； service station ； case manager ； care management