整合社會福利資源，協助弱勢個案重建健康認知、返回社會之護理照護經驗

A Nursing Experience of Helping a Vulnerable Handicapped Person to Reintegrate back into Society

陳明玉(Ming-Yu Chen) ； 林紹雯(Shao-Wen Lin)

《健康促進研究與實務》 1卷1期 (2018/07) Pp. 56-62

https://doi.org/10.29442/HPRP.201807_1(1).0006

摘要

目的：台灣社會弱勢健康差距問題，已逐漸浮現並開始受重視，而造成健康不平等的社會、經濟和環境因素大多在衛生部門的權責之外，因此改革運動需要一個整體性、跨部門的政策發展，處理弱勢群體健康差距的問題。公共衛生護理是社區基層健康照護當中最為核心的專業，故協助個案了解自我健康管理對自己及家庭的重要性是，社區健康照護不可推拖的責任。方法：運用整體性評估，透過密集居家訪談與個案討論正確、自主的健康管理，對生理、心理及照護的問題及帶來的生活影響，促發其改變的動機；引導家屬參與計畫，成功提升個案自信心。透過健康管理模式的介入，提供弱勢及高風險家庭，主動式自我健康管理，連結社區健康照護團隊，凝聚健康醫療照護共識，整合公共衛生體系及社會福利服務，協助弱勢民眾重建自信與價值，重返社會工作崗位。結果：運用收案、收治、管理三階段精神及整合式的健康照護觀念，引導個案學習正確的情緒處理及正向壓力調適技巧。運用漸進式行為改善訓練計畫，提升個案自信心。結合公共衛生體系及社會福利服務資源，提供就業機會促使個案接受重新返回職場。在生活品質方面：情緒感覺心平氣和的時間增加；體力、精力感覺充足比例上升；不良行為習慣改善；慢性病罹病率下降。結論：依據以上成效證明，社區個案健康管理的重要性，若能建立溝通平台，共同協助弱勢群體重新走入社會，改善因病而窮，因窮而病，停止無止境的惡性循環，成功回歸社區生活，是所有社區護理人員努力的目標。

關鍵字

社區弱勢民眾 ； 社區護理師 ； 個案管理

並列摘要

Introduction: Disparities in the health of vulnerable populations are getting more and more attention. Disparities occur across many dimensions, including socioeconomic status, location, and disability status. Ministry of Health and Welfare alone cannot solve the problems. National strategies to reduce disparities in the health of vulnerable populations need to be adopted. The public health nursing is the core function of the community health care. To help patients of the community to manage their health and cognitive their role of the families is the responsibility of the community health care. Materials and Methods: From November 2014 to August 2015, the medical team of the Taichung Hospital set out a series of strategies and actions to achieve its goals, including frequent home visit to discuss the influence of physical and psychosocial outcomes on the health self-management; encouraging family members to play a part of the action plan to build self-confidence of the patient; educating high-risk and vulnerable families concepts of the health self-management by the health management program to change bad habits and health care seeking behavior; and integrating the public health system and the social welfare resources to assist the vulnerable people to rebuild the self-confidence and self-value in order to integrate back to society. Results: the outcomes show that the patient has a significant positive change in the health self-management and the quality of life. The patient's emotion control is getting better and full of energy. The most important thing is that most of the patient's chronic conditions are under control. Conclusion: The results demonstrate the need of the community health management. Helping vulnerable handicapped people to reintegrate back into society, improving the health of the poor, and breaking the vicious circus of poverty and illness would be the first priority of the community medical team.

並列關鍵字

vulnerable populations ； case management ； community nurse