「社區關懷醫師整合性照護-士林、北投區試辦計畫」的發展與成果分析

目的：臺北市立聯合醫院為落實家庭醫師制度，讓每個市民多一個貼心的醫師朋友，提出「醫院型家庭責任醫師制度試辦計畫」及「社區關懷醫師整合性照護- 士林、北投區試辦計畫」。本研究針對社區關懷醫師整合性照護試辦計畫到宅訪視，收案對象的相關資料進行研究。方法：本研究為橫斷性研究，探討社區關懷醫師整合性照護試辦計畫資料，以描述性統計分析收案對象之基本資料、收案來源、專業人員訪視次數等。發現：本研究到宅訪視的收案對象390 人，其中低收入戶331 人次（85%），獨居長者44 人次（11%），中低收入戶22 人次（6%），身心障礙者14 人次(3%)。有部分個案需要到宅訪視2 次以上（含），其原因以社福需求佔最多，達56 人次（57%），其次為心理支持45 人次（45%）與健康需求41 人次（41%），其他為多重用藥佔25人次（25%），特殊境遇佔18 人次（18%），資源轉介佔4 人次（4%）。結論：研究呈現出臺北市弱勢族群的健康服務需求，使個案獲得完整的醫療社福照護，方能落實家庭醫師制度，這些需求也正是我們未來進行社區關懷醫師的主要服務範疇。

關鍵字

家庭醫師制度；整合性照顧；家庭訪視；獨居；社區關懷

並列摘要

Objective: The Taipei City Hospital proposed the Community-Based Family Physician Integrated Care System to implement the family physician system so that every citizen has a considerable physician friend. The family physicians paid home visits to the participants and data were collected for analysis. Methods: This was a cross-sectional study focusing on citizens who joined the service project. We retrospectively collected the anonymous data that described the characteristics of participants and frequency of medical professional visits. Results: A total of 390 participants who received home visits were enrolled from September 2015 through December 2015, in which 353 (91%) were with low or middle-low income, 44 (11%) were living alone, and 14 (3%) were handicapped. Participants who were with low income and living alone had significant needs to be followed-up by physicians and social workers. The reasons of frequent home visit were welfare needs 56 (57%), mental support 45 (45%), medical needs 41 (41%), polypharmacy 25 (25%), special circumstances 18 (18%), etc. Conclusions: Participants who were with low income and living alone were vulnerable groups and needed more health care and social welfare assistance

並列關鍵字

family physician system ； integrated care ； home visit ； living alone

國際替代計量

「社區關懷醫師整合性照護-士林、北投區試辦計畫」的發展與成果分析

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