The Integrated H+Geriatric Clinic Based on Patient Centered

Miao-Yu Liao ； Yu- Chen Hung ； Pi-Shan Hsu ； Hsing-Fang Tsai ； Meng-Chih Lee

《台灣老年醫學暨老年學雜誌》 9卷2期 (2014/05) Pp. 21-21(2)

並列摘要

Objective: The Number of elders in Taiwan will reach 14 % in 2017. They have many problems such as impaired cognition function, delirium, depression, malnutrition and polypharmacy. The Geriatric clinics in Taiwan now are not enough and only one field doctor. The demand of the caregiver cannot be satisfied. Our hospital set up an integrated Geriatric clinic based on patient centered since June 2012. We want to set a pilot integrated care model and evaluate its care quality. Methods: 1. One stop service: We have neurologist, Psychiatric, Family doctor, Traditional Chinese herb doctors, Social worker, nurse practitioner, rehabilitation doctor see our patients at the same time and discuss the care plan. 2. Care management Specialist who take case of elders and family demand with system technology information support. 3. Standard Evaluation forms: We use multiple aspects of Geriatric evaluation forms such as CGA (comprehensive geriatric assessment ) 4. Elderly assistive devices education rooms for the caregivers. Results: From July 2012 to Dec 2013, total integrated Disease declaration rate is 100%, our total patients numbers are 8605. we also set up a tailored-made integrated care plan for each patient. Average age is 81 years old. Their Mean Comprehensive geriatric assessments are as follows: MMSE:24; Geriatric depression scale:4.; MNA-SF 12; ADL 86; IADL 5. The top 3 problems for these elders are balance, dental problems and Insomnia. After Multi- team intervention, their CGA score all increase. The Satisfaction score is 92 %. Conclusions: How to develop an integrated care model for elders is now an important problem in Taiwan. Our hospital set up a pilot geriatric care model based on patient centered .Health aging is our goal. A comprehensive geriatric clinic is very important to the elders.