以復能多元服務試辦計畫發展在地出院「無縫接軌」之居家復能服務模式－花蓮縣為例之初步調查報告

From a Multidimensional Reablement Program to the Development of a New Seamless Transitional Home-based Post-hospitalization Reablement Care Model: a Preliminary Investigation in Hualien County

陳家慶(Jia-Ching Chen) ； 張棋興(Qi-Xing Chang) ； 張逸鴻(I-Hung Chang) ； 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) ； 陳映竹(Ying-Chu Chen) ； 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. 313-329

https://doi.org/10.29461/TGGa.202011_15(4).0007

摘要

國人人口高齡化，慢性病罹患率偏高，身心障礙人數比例逐年攀升，導致長期照顧需求人數增加。花蓮縣高齡、身障族群平均比例甚於全國，再者原住民人口組成近1/3比例且原住民老年人口比例更高達23%，顯見本縣潛在長照需求族群的特殊性與急迫性。花蓮地屬狹長，人口密度與醫療資源分布不均，衰弱失能者出院返家面臨交通不便或照顧者外出工作而就醫復健困難，遑論家住偏鄉或山地區域。如此不僅讓急性期衰弱失能患者重建功能黃金期流失而致更多依賴，也對慢性期失能者功能更加惡化。緣此，由花蓮縣衛生局與花蓮某醫院合作承接長照2.0政策之｢復能多元服務試辦計畫｣嘗試建立橫向連結各專業團隊（醫師－護理－出院準備服務－居家復能），提供垂直式連貫復能服務，讓住院患者出院返家有復能需求即可完全無縫接軌銜接居家復能服務。本報告描述如何建立醫療端與長照社區居家端服務模式，同時介紹住院病患從轉介出院準備到出院返家申請復能多元服務狀況與使用情形提供參考，期望本調查結果可供後續有關政府部門與臨床團隊於住院患者出院連結長照居家復能服務面向的建立與執行上的參考。

關鍵字

出院準備服務 ； 無縫接軌 ； 失能 ； 居家復能 ； 長期照護

並列摘要

The high prevalence of chronic diseases in the aging population and the increasing number of people with disabilities have intensified the demand for long-term care in Taiwan. The proportions of older adults and people with disabilities in Hualien are higher than the national averages. Additionally, nearly one-third of the residents in Hualien are aboriginals, who account for 23% of the county's elderly population; this indicates the urgent need for long-term care in Hualien. Moreover, the majority of the residents and medical resources are aggregated in northern Hualien. Therefore, in remote areas, in-patients becoming frail or disabled upon discharge may face difficulties during subsequent rehabilitation due to problems of communication, hospital inaccessibility, or absence of re-enablement support. To prevent these patients from missing the golden phase of post-hospitalization rehabilitation, our hospital has established a new multidimensional reablement service program in response to the long-term care 2.0 policy and cooperated with the local government authorities to develop a rehabilitation model with home-based reablement service. In this program, a professional interdisciplinary team has been formed to provide a seamless transitional home-based reablement service for patients immediately after they are discharged from the hospital. This study demonstrated the roles of different hospital professionals in organizing and integrating efficient seamless transitional care, using the vertical service model. Additionally, various situations of the patients using the new service model immediately after being discharged from the hospital are presented in this study.

並列關鍵字

Discharge plan ； seamless transitional care ； disability ； home reablement program ； long-term care