探討出院準備服務病人特性與轉銜使用長照服務之影響因素

Characteristics of Patients Receiving Discharge Planning Services and Factors Influencing Their Transition to Long-Term Care Services

鄧喬鳳(Chiao-Feng Teng) ； 陳亮汝(Liang-Ju Chen)

《榮總護理》 40卷3期 (2023/09) Pp. 221-234

https://doi.org/10.6142/VGHN.202309_40(3).0001

摘要

出院準備服務是銜接急性醫療服務與長照服務間重要的橋樑，促使住院病人出院前，即能接受完整的照顧需求評估，進而轉介長照服務。本研究目的為探討出院準備服務病人特性與使用長照服務之影響因素。以回溯方式收集2020年10月至2021年10月於某醫學中心住院病人，依該醫學中心出院準備服務對象之篩選指標，轉介至出院準備服務個管師，進行長照出院準備服務評估者共有673人，其中362人（53.8%）出院後持續接受長照服務。資料收集包括出院準備服務收案條件篩選指標及長照中心評估失能等級之照顧管理評估量表，並以SPSS 25.0進行描述性與邏輯斯複迴歸分析。結果發現經篩選指標接受長照出院準備服務評估的目標族群多為70歲以上高齡者（75.5%）、有管路或醫療資源使用需求（85.0%）、活動及心智狀態不佳者（52.7%）。影響出院準備服務銜接長照服務使用因素為婚姻狀況、身體質量指數（body mass index, BMI）、溝通障礙程度、疼痛程度、皮膚狀況、關節活動度影響日常生活程度、環境障礙、過去一年住院情形、照顧者年齡及有無照顧其他失能家人或3歲以下幼兒等具顯著統計差異。未來期待更優化的出院準備服務的個案分類系統，以利個管師人力妥善評估目標族群，協助病人及家屬出院準備服務轉銜長照服務，達到返家後無縫接軌的照護服務。

關鍵字

出院準備服務 ； 長照服務 ； 轉銜 ； 影響因素

並列摘要

Discharge planning is an important bridge between acute medical services and long-term care services. It can be used to help a patient assess their care needs before discharge and refer them to long-term care services. This study explored the characteristics of patients who received discharge planning services and the factors influencing referral to long-term care services. This was a retrospective study of inpatients from a medical center from October 2020 to October 2021. In total, 673 patients were referred to care management professionals for long-term care discharge planning assessment on the basis of preliminary screenings by the medical center's discharge planning service, of which 362 patients continued to receive long-term care services after discharge (53.8%). The data analyzed included indicators screened for in discharge planning and the results of a care management assessment scale. SPSS 25.0 was used for descriptive statistical analysis and logistic regression. The target population for long-term care discharge planning screening comprised mostly individuals aged >70 years (75.5%), individuals with high demand for tube usage or medical resources (85%), and individuals with low activity and a poor mental state (52.7%). Factors significantly influencing discharge planning for transfer to long-term care services were marital status, body mass index, severity of communication barriers, severity of pain, skin health, the influence of joint mobility on daily life, the number of environmental obstacles, hospitalizations in the previous year, caregiver age, and whether the patient cared for other disabled family members or children aged <3 years. In the future, patients should be classified more effectively to enable the staff to effectively evaluate the target population, assist patients and their families in timely referral to long-term care services, and achieve seamless care connection.

並列關鍵字

discharge planning ； long-term care service ； transition ； influencing factor

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