個管師於社區整合照顧服務之經驗

The Experience of Care Managers in Integrated Community Care Service

陳麗如(Li-Ju Chen) ； 周姚均(Yao-Chun Chou) ； 楊美如(Mei-Ju Yang) ； 翁瑞萱(Ruey-Shiuan Ueng) ； 孫文榮(Wen-Jung Sun) ； 陳靜琳(Ching-Lin Chen) ； 劉志光(Chih-Kuang Liu) ； 黃勝堅(Sheng-Jean Huang) ； 曾湘玲(Hsiang-Lin Tseng)

《北市醫學雜誌》 15卷1期 (2018/03) Pp. 21-27

https://doi.org/10.6200/TCMJ.201803_15(1).0003

摘要

落實在地老化，失能者安心終老，不僅是世界各國的趨勢也是目前長照2.0重要政策。目前世界各國的趨勢都採取在地老化、健康老化等解決策略，支持社區長期照護體系的建構，希望以在地服務滿足在地人的照顧需求，延長停留社區時間。因應長期照顧需求，臺北市首推社區整合照顧模式，期透過佈建綿密的長照服務資源，提供在地、即時、便利的連續社區照顧。個案管理師是社區整合照顧服務中靈魂人物，本文旨在描述臺北市區域社區整合照顧服務之個案管理師在過社區整合照顧計畫經驗分享如何稱職扮演需求評估、照顧計畫及串連社區跨專業之合作資源，提供個別且多元之照顧管理服務，讓失能者延緩失能，提升生活及尊嚴之社區照顧品質。

關鍵字

個案管理師 ； 社區整合照顧服務 ； 照顧管理

並列摘要

Implementation of aging in vicinity and aging peaceful for disabled have become global trends and main policies of long-term care 2.0. At present, the whole world is adopting these two strategies to support the development of community long-term care system, hoping to use the local services to fulfill the needs of local people and extend their stays in the community. In response to the needs of longterm care, the Taipei City was the first to promote community integrated care model, hoping to provide local, instant, and easy to use continuous community care through the development of widely distributed long-term care resources. The case manager is the soul of the community integrated care service. This article aims to explore the case management experience of the Taipei regional community integrated care service to play a competent role in need assessments, care programs, and linking crossdiscipline collaborative community resources, and to provide individual and diverted care management services, so that the disabled may delay the loss of function and raise life quality and dignity.

並列關鍵字

case manager ； community integration care services ； care management