無縫接軌之創新出院準備服務模式－以南部某醫學中心為例

Integrated Discharge Plan: Seamless Transition from Hospital to Home

魯英屏(Ying-Ping Lu) ； 高詠彥(Yung-Yen Gao) ； 王郁鈞(Yu-Chun Wang) ； 王勁慧(Jin-Huei Wang) ； 梁志光(Chih-Kuang Liang) ； 周明岳(Ming-Yueh Chou) ； 黃美智(Mei-Chih Huang) ； 林麗英(Li-Ying Lin) ； 顧艷秋(Yan-Choiu Ku) ； 林育德(Yu-Te Lin) ； 陳芬婷(Fen-Ting Chen) ； 林妙玲(Miao-Ling Lin) ； 李素華(Su-Hua Lee) ； 黃志中(Joh-Jong Huang)

《台灣老年醫學暨老年學會雜誌》 13卷4期 (2018/11) Pp. 253-264

https://doi.org/10.29461/TGGa.201811_13(4).0004

摘要

高齡長者常因為疾病關係住院而產生失能，出院後需要安排長照服務。然而，當失能長者返家時，如需接受居家式長照服務，需要等待照管中心安排長照管理專員訪視與服務遞送，因而產生照顧上的空窗期，造成家屬壓力。因此，醫院透過與地方政府與長照服務單位相互合作，讓出院準備服務與居家式長照服務無縫接軌，出院前完成長照需求評估與核定，並安排好各項居家式長照服務，完成長照服務遞送單位交班聯繫，讓失能長者在出院時可立即獲得服務，減少不確定性與空窗期，使長者與家屬能安心返家。

關鍵字

老年人 ； 出院準備服務 ； 長期照護 ； 跨專業團隊 ； 無縫接軌

並列摘要

Elderly patients often become disabled during hospitalization and dependent on long-term care service after discharge. However, when that happens, the current practice requires a disabled elderly patient to be discharged first and then wait for a certain period of time during which a case manager is assigned to visit the patient for assessment his or her need for home-based long-term care service. The service is delivered when the assessment deems it necessary. The practice creates a ＂gap＂ between hospital discharge and service delivery that causes considerable anxiety and stress for the patient's family members. If the assessment and arrangement for home-based long-term care service can be conducted prior to discharge, elderly patients will be able to expect with certainty the needed long-term care service upon returning home. Therefore, hospital, competent government authority, and service provider should be integrated into seamless cooperation to facilitate no-gap timely delivery of home-based long-term care services for elderly patients and their families.

並列關鍵字

elderly ； discharge plan ； long-term care ； transition care ； interdisciplinary team