- 學位論文
出院準備銜接長照2.0服務之個案持續使用服務之相關因素探討-以雲林縣為例
Factors Related to the Continuous Use of Services Provided by the Second Ten-Year Long-Term Care Plan Among Discharging Planning Cases in Yunlin County
摘要
研究背景及目的: 雲林縣自2017年推行「銜接長照2.0出院準備友善醫院獎勵計畫」至今發現參與出院準備銜接長照2.0服務之民眾，出院後完全沒有使用服務或不願意再繼續使用而結案者不在少數，費時費力評估及協助後續的服務連結，卻是結案收場，無法實踐所謂的長期照顧服務，亦無法發揮中央推行出院準備銜接長照2.0服務美意。本研究目的有三:(1)探討雲林縣民眾在出院準備後長期繼續使用服務超過9個月以上的比例。(2)探討雲林縣民眾經出院準備流程後結案的類別。(3)運用Andersen 的行為模式（behavioral model）探討雲林縣民眾在參與出院準備銜接長期照顧2.0以及影響繼續使用長照2.0服務之相關因素。 研究方法: 採病歷回顧方法，回顧衛生福利部照顧服務資訊管理平臺(以下簡稱CMS系統)資料中由雲林縣出院準備醫院端自2020年1月1日至6月30日期間由CMS系統登錄，完成失能級數評估之859筆資料，分析其至2021年3月31日間結案之比例及結案類型，並進一步以 Andersen 行為模式及使用統計軟體 SAS 9 .4 (SAS institute Inc., Cary, NC) 軟體進行資料的建檔及分析；先以卡方檢定「前傾因素」、「使能因素」、「需求因素」 等構面中的各自變項與「是否繼續使用長照2.0服務」此應變項的關連性；之後則使用羅吉斯迴歸分析（ Logistic regression Analysis） 以驗證「前傾因素」、「使能因素」、「需求因素」包括失能級數及不同服務的使用包含(B碼)日常生活照護、(C碼)專業服務、(D碼)交通接送服務、(E、F碼)輔具服務及居家無障礙環境改善服務、(G碼)喘息服務等、對於「是否繼續使用長照2.0服務」的影響因素及整體預測能力。 研究結果: 本研究結果發現雲林縣住院民眾經出院準備銜接長期照顧服務後繼續使用服務超過9個月以上的比例僅占整體樣本數的21.36%；其中結案之結案類別共分24類，如個案死亡及家人自行照顧，而最多的為機構入住，佔所有結案之(24.72%)；而影響個案持續使用服務的因素主要來自於使能因素之疾病診斷、疾病總數及有無身障證明，以及需求因素之失能級數及不同服務。影響服務持續使用的因素以需求因素為主的有疾病診斷中罹患骨骼疾患對持續使用長照服務有顯著的影響(P<0.05)，身障證明的個案(OR=2.435， P<0.01 )、疾病總數愈多的個案(OR=1.378，P <0.01 ) 繼續使用服務的機率比較大、有使用(B碼)日常生活照護(OR=15.618，P <0.001 )、(D碼)交通接送服務(OR=4.078，P <0.001 )及(E、F碼)輔具服務及居家無障礙環境改善服務的個案(OR=2.361，P<0.001 )案其繼續使用服務的機率比沒有使用的個案機率大；單獨使用喘息服務的個案結案率比較高(OR=0.477，P<0.001 )。失能級數2級繼續使用服務的機率比失能級數8級的機率大 (OR=5.337，P <0.05)。 研究結論: 雲林縣進行「銜接長照2.0出院準備友善醫院獎勵計畫」持續使用長照服務的人數偏低，其中最常見的結案原因是機構入住，同時喘息服務使用也有較高風險結束長照2.0服務使用。推測出院時由於家屬未準備好，所以希望先以機構喘息服務優先，結果之後個案就繼續接受機構照顧。建議考慮未來「出院準備銜接長照2.0服務」個案應避免出院單獨核定直接使用機構喘息服務，建議可多搭配其他居家式或社區式的服務提高服務持續使用率，喘息服務可以等到照專初評時再提供。
並列摘要
Backgrounds: Yun Lin County has promoted the policy of “linking long-term care plan version 2.0 services to discharge planning” since 2017. However, a lot of hospital-discharged people who were prescribed with long-term care services before leaving the hospitals but did not continue to use the services. The purpose of this study was to (1) explore the percentage of hospital-discharged people who were prescribed with long-term care services and continued to use long-term care (LTC) services over 9 month period of time; (2) explore reasons of people dis-continued their use of long-term care services; (3) use Andersen Health behavioral model to explore factors associated with continuous use of long-term care services among hospital-discharged people who were linked to the policy of “linking Long-term care plan version 2.0 services to discharge planning” in Yun Lin County. Methods This is a retrospective study for extracting clients’ records from the Case-mixed System(CMS system) of the Ministry of Health and Welfare from January 1, 2020 to March, 31st, 2021. Hospital-discharged clients’ record in Yun Lin county who were assessed and linked to long-term care services from January 1, 2020 to June 30th, 2020 were included for analysis. As a result, 859 records which logged into the system during the study period were extracted for analysis. The current study first analyzed the percentages and the types of these cases closed until March, 31st, 2021, and then we used the Andersen’s Health Behavior ModelLogistic regression analysis was applied using SAS 9.4. as a framework and investigated the impacts of “predisposing factors”, “enabling factors” and “need factors" on the continuous use of LTC 2.0 service. Both disability levels and long-term care services, such as (Code B) daily activity care services, (Code C) professional care services, (Code D) transportation services, (Code E and F) auxiliary appliance devices and home accessibility improvement services, and (Code G) respite service. Results The results of this study showed that about 21.36% the people who were discharged from the hospitals and connected to the LTC services continued to use LTC services for more than 9 months in Yun Lin County. There were in total 24 types of reasons, such as institutionalization, cases died, and famly take care themselves, contributed to clients’ discontinuous use of long-term care services. The largest number is institutional occupancy which is accounting for 24.72% of all closed cases. The factors which affected the continuous use of services in cases mainly come from need factors such as disease diagnosis, total number of diseases and proof of disability, as well as disability levels and differences in need factors services. The factors promoting the continuous use of the LTC service included having orthopedic-related disease (p <0.05 ), with a disability certificate (OR =2.435 , p <0.01 ), with more chronic illness (OR =1.378 , p <0.01 )Also, using more home-care services (OR =15.618 , p <0.001 ), transportation services (OR =4.078 , p <0.001 ), or using Code (E and F) auxiliary appliance devices and home accessibility improvement service (OR =2.361 , p <0.001 ). However, when using respite care service, the chance of continuous use LTC services decreased, (OR=0.477, p <0.001), and hospital-discharge clients were 53% more likely to discontinuous their LTC service use. The probability of continuing to use the service with a disability level of 2 is greater than level of 8 (OR=5.337p <0.005). Conclusions Yun Lin county has promoted the continuous use of long-term care services through promoting the policy of “linking long-term care plan version 2.0 services to discharge planning”, but the rates of continuous use was relatively low. The most common reason of case closed was institutionalization. Since using respite care service was associated with discontinuous use of long-term care services, it is possible that families prefers to use respite care when they are not comfortable with taking care of the elderly at home. After using respite care services, the elderly continued to stay in the institutions and discontinued their use of long-term care services. In the future, the government shall recommend discharge planners not to prescribe institutional respite service after the clients’ discharge from the hospitals, and instead, discharge planners shall prescribe more home-based or community-based care services to increase the rate of continuous use of services. Respite care services shall be prescribed a couple months after clients’ discharge when case managers visit them at home.