居家護理師在社區整合型照顧中個案管理員的角色與契機

Roles of Case Managers and Opportunities for Home Nursing Staff in Community Integrated Care

呂郁芳(Yu-Fang Lu)

《榮總護理》 35卷3期 (2018/09) Pp. 261-268

https://doi.org/10.6142/VGHN.201809_35(3).0005

摘要

人口老化，高齡人口增加快速，是當今全世界共同要面對的問題，而人口老化嚴重衍生出的就是照顧問題，為了因應老人的照顧問題，世界各國均推行各項的長期照顧政策，而政策的最高目標是『在地老化』（aging in place），以開發居家式照護或社區式照護政策為主，在就地老化的目標下，我們期待給老人一個安心又完善的服務，由專業人員到社區或家中做需求評估，提供跨專業整合服務及資源連結，這就是所謂的社區整合型照顧。而社區整合型照顧的主要核心人物是個案管理員，當中護理人員是最適合擔任此角色的人員。從提供個案需求評估、計畫的訂定、照護的執行、預防、疾病的衛教、成效追蹤、資源的連結，以及提供一站式的服務，提高服務效能，減少個案所需的照護時數，來提升照護品質。為了鼓勵與訓練更多護理人員能投入長照服務，衛福部於2018年擬定鄰里居家護理所倍增計畫，目標是以護理人員為主導、社區為基礎、顧客為中心，發展社區式照護資源，透過政府經濟政策支持，佈建社區照顧家庭的居家護理師，讓護理工作可以從機構出發，更深入社區從事照護工作。居家護理師身兼重任，需要打破舊思維，不斷增加長照服務的知識和技能，且要勇於嘗試一些創新服務，如足部照護、失智症照顧，進而提供多元的服務，發揮個案管理員的功能，真正做好社區整合型照顧的服務。

關鍵字

社區整合型照顧 ； 居家護理師 ； 個案管理員

並列摘要

Population aging has become a common problem worldwide and leads to the issue of elderly care. To respond to elderly care requirements, all countries have implemented long-term care policies. The ultimate goal is ＂aging in place.＂ To develop home- or community-based care policies, with the goal of aging in place, we intend to provide older adults with a reliable and comprehensive service. Needs assessments conducted by professionals regarding community or home care provide cross-professional integration services and resource links. This is called community-integrated care. The case manager is the key role in this project, and nursing staff members are suitable for this role. They provide various types of service to enhance the quality of care, including case-needs assessments, plan formulation, care implementation, prevention, diseases education, effectiveness tracking, resource linking, and one-stop services, to improve effectiveness and reduce the care hours required for individual cases. To encourage and train more home nursing staff to invest in long-term services, in 2018, the Ministry of Health and Welfare has operated a project aimed at increasing home care agency. With the support from government's policy, they aim to enable home nursing staff to lead the project of developing community-based care resources, which are based on the community and the customers, and to train more home nursing staff to provide care service in the community. In this case, nursing is not limited to institutions and is also performed in the community. In addition, home nursing staff could improve their skills, increase their knowledge, and try to provide multiple innovative services, such as foot care and dementia care. Thus, they can provide multiple services, fully assume the functions of the case manager, and perform strongly in community-integrated care.

並列關鍵字

community-integrated care ； home care nurse ； case manager

參考文獻

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