提升內科病房衰弱高齡急性後期照護轉銜率

衰弱高齡急性後期照護計畫為銜接急性醫療與長期照護之橋梁，可提升高齡病人的日常生活功能與心智狀態，亦減少30天再住院率。然而，本病房之轉銜率不彰引發執行動機。專案目的為轉銜率由1.6％提升至2.7％。轉銜率低的影響主因包括個管師篩選量能不足，評估與說明及後續追蹤管理耗時，轉介表單未能整合，家屬與醫療團隊對轉銜計畫之認知不足，缺少急性後期照護（Post-Acute Care, PAC）PAC轉銜標準流程與角色分工等。改善對策包括發展衰弱高齡PAC應用程式（Application, APP），制定及整合簡化篩選轉介單及建立流程與職責分工，發展PAC輔助衛教資源，與舉辦在職教育等。專案結果轉銜率提升至4.7%並穩定維持。本專案有效提升轉銜率，透過整合性無縫之持續照護得到更好的生活品質，改善之相關策略可平行推展至其他病房蔚為借鏡。

關鍵字

衰弱；高齡；急性後期照護；轉銜率

並列摘要

Elderly acute post-care serves as a bridge between acute care and long-term care, improving physical ability and mental status while reducing the 30-day re-hospitalization rate in the elderly, although the low transfer rate in this ward triggered execution motivation. The aim was to increase the transfer rate from 1.6% to 2.7%. The main reasons for the low transfer rate included an insufficient selection of individual supervisors, time-consuming assessment and explanation and follow-up management, failure to integrate referral forms, insufficient knowledge of families and medical professionals on the PAC, and lack of PAC transfer standard process and role division. Improvement measures included the development of PAC APP, the formulation and integration of simplified screening referral forms, the establishment of procedures and division of responsibilities, the development of PAC supplementary health education resources, and the organization of on-the-job education. As a result, the project's conversion rate increased to 4.7% and remained stable. This project effectively increased the transfer rate and improved the quality of life through integrated and seamless continuous care. The related improvement strategies could be extended to other clinical settings.

並列關鍵字

frail ； elderly ； post-acute care ； transfer rate

參考文獻

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