醫務社會工作者在出院準備服務的任務與價值

The Task and Value of Medical Social Workers in the Discharge Planning

劉靜女(Ching-Nu Liu) ； 孫馥敏(Fu-Min Sun) ； 王實之(Shih-Chih Wang)

《北市醫學雜誌》 15卷4期 (2018/12) Pp. 14-23

https://doi.org/10.6200/TCMJ.201812_15(4).0002

摘要

協助病人處理出院準備需求是社會工作進入醫院的原動力，也是醫務社工傳統且熟悉的工作。面對與日俱增的慢性病和老年人口，長照2.0提出「延伸出院準備」服務，強調從醫院到社區無縫隙、連續性的照顧服務，社區化的照顧需求導向，增加出院準備服務的需求範圍和複雜度。醫務社工發揮專業角色，促進跨團隊整合的照護模式，協助病人順利轉銜，是本文探討的重點，期透過文獻回顧和實務經驗的回顧與反思，呈現醫務社工人員在以病人、家庭為中心、以社區為基礎的出院準備團隊中之任務與價值。本文建議醫務社工的出院準備任務是需透過在病人端、醫院端和社區端完整的需求與資源評估，強化以病人和家屬為中心的服務，共同發展可行之出院準備計畫、協調決策過程中可預期的衝突與歧見、倡導與開發未被滿足需求和資源、減輕家庭照顧者負荷、發展落實出院追蹤模式，以確認病人和家屬返回社區後的適應，才能使家庭重拾平衡，維持其最佳的社會和經濟狀態。

關鍵字

出院準備 ； 醫務社工在出院準備團隊的任務與價值 ； 跨團隊整合的照護模式

並列摘要

Helping patient managing discharging is the motive force why social work is required in hospital, and it is a traditional and familiar task for medical social workers. Facing the growing chronic diseases and aging, the Long-Term Care 2.0 program provides an ＂extended discharge planning＂ service, emphasizing a seamless and continuous services from the hospital to the community which increases the scope and complexity of a discharging plan. This article discusses how medical social workers may play a professional role in promoting an interdisciplinary collaboration care model which assist patients to transit between care services smoothly. Through literature review and authors' reflection, this paper presents the tasks and values of social worker in a patient/families centered and community based discharging planning team. This article indicates that the task of social worker in discharging planning is to comprehensively assess the needs and resources of a patient, hospital, and community, develop a feasible discharging plan with patients and their families, coordinate predictable conflicts and disagreements in the decision-making process, satisfy the unmet needs and develop new resources, relieve caregivers' burden, implement follow-up, and assure the adaptation of patients and their families after returning to the community. With all that, the family may be rebalanced and maintain their best social and economic status.

並列關鍵字

discharging planning ； medical social work ； transitions of care ； social work role and intervention