臺灣和日本居家復健制度之比較－臺北市立聯合醫院與長野縣佐久醫療體系經驗分享

Comparison of the System of Home-Based Rehabilitation Between Taiwan and Japan: Experience of the Taipei City Hospital and the Saku Medical Care Institutions in Nagano

李旻璋(Min-Chang Lee) ； 黃勝堅(Sheng-Jean Huang) ； 莊美幸(Mei-Hsing Chuang) ； 李秉翰(Pin-Han Lee) ； 曹昭懿(Jau-Yih Tsauo) ； 翁林仲(Lin-Chung Woung)

《物理治療》 43卷3期 (2018/09) Pp. 193-202

https://doi.org/10.6215/FJPT.201809_43(3).0001

摘要

臺灣人口快速老化，失能人口相對應迅速成長。急性疾病發生後，居家醫療可銜接住院治療與長期照顧的空窗期。從住院到居家服務傳遞的連續性、周全性和協調性是居家醫療成功的關鍵因素。居家復健則可促進病人生活品質、改善日常生活功能和減少失能與次級疾病發生。本文目的為介紹日本與臺灣的居家復健制度與經驗分享；日本透過介護保險與醫療保險資源的協調，提供急性期、急性後期、慢性期，到生命末期的居家醫療（含復健）服務，長野縣佐久醫療體系藉由醫療垂直整合，與出院準備服務幫助病人在家終老。臺灣居家醫療才剛起步，透過全民健康保險急性後期照護與長期照顧十年計畫傳遞居家復健服務，臺北市立聯合醫院串聯出院準備服務、急性後期整合照護計畫，幫助病人成功返家，減少再住院。出院準備服務的實踐，以及居家復健制度應當更加全備，幫助病人在地老化、在家善終。

關鍵字

居家復健 ； 居家醫療 ； 急性後期照護 ； 長期照顧 ； 出院準備

並列摘要

Population in Taiwan is aging rapidly, and people with disability are increasing correspondingly. Home medical care can connect the gap between hospital care and long-term care after an acute episode. The keys to successful home medical care are continuous, comprehensive, and coordinate service delivery from hospital to home. Home-based rehabilitation can improve patients' quality of life, activities of daily living, and reduce disability and secondary complications. The purposes of this article are to introduce the system of home-based rehabilitation and compare the experiences between Japan and Taiwan. In Japan, through the coordination of the service of long-term care insurance and medical insurance, home medical care including home-based rehabilitation could be provided at acute, post-acute, chronic, and end-of-life stage. The Saku Medical Care Institutions in Nagano help patients aging and dying at home by medical vertical integration, and discharge planning. The home medical care in Taiwan have been started, which is delivered by Post-Acute Care of National Health Insurance and Ten-Year Long-term Care Program. Care team of Taipei City Hospital helps patients go home successfully and reduce readmission through discharge planning and Post-Acute Care program. To help patients aging in place and dying at home, the discharge planning should be implemented, and the system of home-based rehabilitation should be more comprehensive.

並列關鍵字

Home-based rehabilitation ； Home medical care ； Post-acute care ； Long-term care ； Discharge planning