高齡精準健康照護－Geri-FORCE個管系統

Precision Health Care for Older Adults: The Geri-FORCE Case Management System

岳芳如(Fang-Ru YUEH) ； 林奕璇(Yi-Hsuan LIN) ； 賴柏亘(Po-Hsuan LAI) ； 胡芳文(Fang-Wen HU) ； 張家銘(Chia-Ming CHANG)

《護理雜誌》 69卷2期 (2022/04) Pp. 13-18

https://doi.org/10.6224/JN.202204_69(2).03

摘要

高齡者健康問題常是多重共病與老年病症候群交錯，且併有心理社會層面等問題，過去以單一疾病為主的醫療照護模式，恐難適當處理高齡者健康問題。因此，本文從個案管理架構（評估、計畫、執行、協調及評值與互動）出發，結合老年周全性評估、跨專業團隊整合及連續性照護的服務輸送，討論以高齡者為中心的照護模式。為建立高齡精準健康照護系統，台灣高齡照護暨教育協會在國民健康署的計畫下，發展出台灣高齡照護成效及增能模式（geriatrics formulated by outcome related care & empowerment, Geri-FORCE模式），期能將高齡個案管理機制結合Geri-FORCE模式，發展資訊化高齡照護個管系統，能更有效率為高齡者找出主要健康問題，並量身制訂精準且個別化的連續性整合照護計畫，以提升高齡照護品質，預防及延緩衰弱或失能，進而減輕醫療與長期照護成本支出。

關鍵字

精準照護 ； 高齡照護模式 ； 個案管理

並列摘要

Health problems in older adults are often concomitant with multiple comorbidities and geriatric syndromes that involve the psychological and social domains. Traditional models of disease care address the health problems of older adults inadequately. Therefore, we applied a case management framework (assess, plan, act, coordinate, evaluate and interact) to discuss how to implement an elderly-centered approach to integrated care that integrates comprehensive, multidisciplinary, and continuous care. The Geriatrics Formulated by Outcome Related Care & Empowerment (Geri-FORCE) was developed by the Formosan Association of Care and Education for the Seniors to help establish a geriatric case management system grounded in precision health care. We propose developing an informatics technology system for older adults that integrates the Geri-FORCE model with case management. This system should accurately identify the main health problems in older adults and provide a care plan that is patient-tailored, integrated, and continuous. We expect that the developed Geri-FORCE case management system will improve quality of care and promote health while reducing care burdens and costs.

並列關鍵字

precision health care ； geriatric care model ； case management

參考文獻

吳孟嬪、馮容莊、施至遠、徐愫萱、鄒淑萍、朱怡蓁、黃勝堅（2019）．從醫院到社區的全人照護—建構完善的出院準備服務．北市醫學雜誌，16（附冊），10–24。[Wu, M.-P., Feng, R.-C., Shin, C.-Y., Hsu, S.-H., Chou, S.-P., Chu, I.-C., & Huang, S.-J. (2019). Holistic care from hospital to community-building a comprehensive discharge planning service. Taipei City Medical Journal, 16(Suppl.), 10–24.]

施勝烽、劉恆忻、陳映儒、蕭婷、林翊瑄（2017）．高齡友善從院內到院外：出院準備計畫服務之探討．福祉科技與服務管理學刊，5（3），241–256。[Shin, S.-F., Liu, H.-H., Chen, Y.-J., Hsiao, T., & Lin, Y.-H. (2017). Creating elder-friendly environments in hospitals and communities: Research on discharge planning service. Journal of Gerontechnology and Service Management, 5(3), 241–256.]

胡芳文、王英偉、李佳綺、岳芳如、羅玉岱、吳建遠、王麗娟、鍾遠芳、沈珊妤、陳宜君、黃基彰、林岱嬋、張家銘（2020）．臺灣醫院長者友善照護模式之發展與現況初探．醫療品質雜誌，14（6），20–26。[Hu, F.-W., Wang, Y.-W., Lee, C.-C., Yueh, F.-R., Lo, Y.-T., Wu, C.-Y., Wang, L.-C., Chung, Y.-F., Shen, S.-Y., Chen, I.-C., Huang, C.-C., Lin, D.-C., & Chang, C.-M. (2020). Development and investigation of the age-friendly health care model in Taiwanese hospitals. Journal of Healthcare Quality, 14(6), 20–26.]

胡芳文、游詠晨、陳清惠、張家銘（2017）．美日經驗看台灣高齡進階護理師角色的發展．台灣老年醫學暨老年學雜誌，12（2），75–90。[Hu, F.-W., Yu, Y.-C., Chen, C.-H., & Chang, C.-M. (2017). Development of gerontological advanced practice nurses in Taiwan: From experiences of the America and Japan. Taiwan Geriatrics & Gerontology, 12(2), 75–90.]

張家銘、蔡智能（2003）．老年人之周全性評估．台灣醫學，7（3），364–374。[Chang, C.-M., & Tsai, C.-N. (2003). Comprehensive geriatric assessment. Formosan Journal of Medicine, 7(3), 364–374.]