運用團隊整合模式銜接長照2.0服務之成效研究

目的：為提升老人及失能者照護品質，某醫院結合衛福部及衛生局資源，運用團隊整合模式由醫師、出院準備個管師，及衛福部照管專員提前評估，以期再入院率下降及提升出院滿意度。方法：蒐集自2017年6月至2018年5月65歲以上急性腦中風或急性髖關節骨折個案，運用團隊整合模式，統計個案14天再入院率及以問卷詢問出院病人對後續照護的滿意度，再以Chi-square test分析成效。結果：個案共349人；前一年度65歲以上腦中風或急性髖關節骨折個案共316人，其14天再入院率為0.95％；研究期間為0.57％，下降比率為40.12％（p＜0.001）。前一年度病人滿意度為83.46％；研究期間達94.52％，提升比率為13.25％（p＝0.015）。結論：本研究發現住院時即由醫療團隊介入，評估後續照顧需求並轉介長照服務，更能提升出院病人滿意度並降低再入院率。

關鍵字

團隊整合照護；長照2.0服務；出院準備； 14天再入院率

並列摘要

Background: As the aged population rises, care for the elderly is an important issue. A hospital in Changhua County established a discharge protocol using the resources of the Ministry of Health and Welfare and the Public Health Bureau within the county, in order to improve the quality of care for the elderly and the disabled. A interdisciplinary model providing doctors' assessment from patients were admitted and a discharge planning manager was consulted with regard to services before discharge to ensure that long-term resources were optimized, in order to reduce the readmission rate and to increase the satisfaction of discharged patients. Methods: Cases of acute stroke or acute hip fracture were enrolled from June 2017 to May 2018who met the requirements of Long-term care 2.0. A interdisciplinary model was used to assess the care needs of patients and to provide adequate referrals and consultations. Statistics cover the 14-days readmission rate and the satisfaction of the discharged patients, as determined using aquestionnaire. Statistical analysis used a Chi-Square test. Results: From June 2017 to May 2018, a total of 349 patients over the age of 65 with acute stroke or acute hip fracture were studied. From June 2016 to May 2017, there were 316 patients over 65 years old with stroke or acute hip fractures and the 14-day readmission rate was 0.95%. From June 2017 to May 2018, the figure was 0.57%, which showed the decreasing rate of 40.12% (p ＜ 0.001). The satisfaction of the discharged patients was 83.46% from June 2016 to May 2017 and increased by 94.52% from June 2017 to May 2018. An increase of 11.06% was revealed, and the rate of increase is 13.25% (p=0.015). The results for the readmission rate and satisfaction show improvements and are statistically significant. Conclusions: The results of this study show that there is a strong relationship between early intervention using a interdisciplinary model and an increase in the satisfaction of patients who are discharged from hospitals and a reduction in readmission rates, which benefits patients, hospitals and government.

並列關鍵字

Interdisciplinary model ； Long-term care 2.0 ； Discharge planning ； 14-days readmission rate

國際替代計量

運用團隊整合模式銜接長照2.0服務之成效研究

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