初探出院準備連結居家復能無縫接軌服務模式之成效

Pilot Investigation on Home-care Reablement Services with a Seamless Transitional Care Program after Hospital Discharge

陳家慶(Jia-Ching Chen) ； 張棋興(Qi-Xing Chang) ； 吳孟莼(Mong-Chune Wu) ； 宋惠娟(Huei-Chuan Sung) ； 羅慶徽(Ching-Hui Loh) ； 林金蘭(Chin-Lan Lin) ； 林淑緩(Shu-Huan Lin) ； 朱家祥(Chia-Hsiang Chu) ； 黃秀茹(Hsiu-Ju Huang) ； 梁忠詔(Chung-Chao Liang)

《台灣老年醫學暨老年學會雜誌》 15卷4期 (2020/11) Pp. 257-270

https://doi.org/10.29461/TGGa.202011_15(4).0002

摘要

目的：高齡者住院於出院返家易有身體功能衰退表現。本研究探討高齡住院患者連結出院準備服務於返家後接受短期居家復能（home-care reablement services）介入在身體活動功能成效。方法：收案自花蓮慈濟醫院2019年8月至11月住院患者於出院返家接受物理治療師提供居家復能2到3個月的介入。記錄出院返家到第一次接受居家復能服務遞送時間，平均每月服務次數，評估身體功能以巴氏量表（Barthel index）、老人活動量表（Elderly mobility scale）、握力（grip strength）與走路功能分級（Functional ambulation classification）於介入前與第3個月或期間內自動結案者（但至少需接受3次以上復能服務）評估成效。結果：40位平均76.7±9.8歲個案完成前、後測，個案返家後平均4.9天接受第一次介入，每月平均1.9組居家復能，接受服務期程平均50.2±35.4天，身體功能表現提昇分別在巴氏量表平均20分、老人活動功能量表3.5分、握力2.6公斤、與功能性走路達顯著進步。結論：高齡住院患者連結出院準備服務於返家接受短期居家復能介入有效改善身體活動功能。

關鍵字

出院準備 ； 居家復能 ； 無縫接軌 ； 老人 ； 失能

並列摘要

Objectives: Elderly in-patients often experience functional decline after discharge. This study investigated the physical functions of elderly patients with frailty or disabilities after hospital discharge, when receiving home-care reablement services (HRSs) with a seamless transitional care program. Methods: Elderly patients admitted to Tzu-chi Hospital between August and November 2019 were recruited, after they were discharged and received HRS from a physical therapist for 2-3 months. The duration between the first HRS delivery and hospital discharge and the average number of times HRS was delivered were recorded for each participant. Physical functions were evaluated using the Barthel Index (BI), Elderly Mobility Scale (EMS), grip strength, and Functional Ambulation Classification (FAC), before the intervention and at the third month or when the participants opted to end the HRS within the third month. Results: In total, 40 participants (average age: 77 years) completed all pre- and post-study evaluations. The first HRS was delivered to the participants at an average of 4.9 days after discharge. On average, participants received HRS 5.6 times (1.9 sets) per month for a duration of 50 days prior to the post-study evaluation. Participants who received post-discharge HRS showed the following significant improvements: BI scores increased by 20 points, EMS scores by 3.5 points, grip strength by 2.6 kg, and FAC scores by 1.1 points. Conclusion: Elderly patients with frailty or disabilities who received HRS after hospital discharge with a seamless transitional care program showed significant improvements in their physical functions.

並列關鍵字

discharge plan ； home-care reablement services ； seamless transitional care ； elderly ； disability