- 期刊
推動出院準備服務與長期照顧服務之整體化－以雲林縣某區域教學醫院為例
Integration of Medical and Community Long-Term Care Services- A Case Study of Yunlin County Regional Teaching Hospital
摘要
目的：出院準備服務在長期照顧服務資源轉介扮演非常重要角色。2019年本院住院族群65歲以上佔多數，佔58.9%，而符合長照服務資格者出院後申請長照服務比率低於5成，而且在出院準備服務收案率及轉銜長照服務比率均偏低。在高齡化趨勢下，急性期除提供醫療服務外，更需社區長照服務的介入，促使有長照服務需求的老人，出院後能持續獲得服務。因此，希望藉由本專案的執行能提升老人出院準備服務收案率並改善初篩重覆評估與服務轉銜率低的困境，以達到社區健康促進醫院使命及專業價值。方法：於2020年1月至6月透過「出院準備服務管理系統」及「衛生福利部照顧服務管理資訊平臺」查詢本院2018年1月至2019年12月出院準備服務轉銜長期照顧服務之執行情形，以特性要因圖分析、檢討，針對出院準備服務收案率低、個案初篩重複評估比率高及轉銜長期照顧服務人數低等原因進行策略執行，如修訂出院準備服務銜接社區長期照顧服務流程、科室宣導及安排出院準備銜接社區長期照顧服務教育訓練、病房設置出院準備服務種子人員、成立「社區健康長照中心」、訂定績效獎勵制度等。結果：出院準備服務收案率由36.7%升至66.7%、出院準備服務個案初篩重複評估率從4.27%降為0%；出院準備服務轉銜長照服務人數從284人提升為306人。結論：以「友善醫院、樂活社區」之理念，藉由出院準備服務銜接社區長照服務，讓家－醫院－社區串連，並透過社區據點、健康管理等個管模式介入，讓民眾得以在地老化，達到醫院永續服務之目標。
並列摘要
Discharge planning services are an important element of long-term care services. In 2019, our hospital found that the proportion of inpatients aged over 65 years was 58.9%, and the rate of long-term care service application after discharge from the hospital was less than 50%. Furthermore, acceptance and transfer rates were low. In the acute phase of a disease, providing medical services is necessary. Furthermore, providing long-term care services to community-dwelling older adults is essential. Such services affect older adults' quality of life and health care costs. Therefore, this project aimed to improve discharge planning application, initial screening assessment, and service transfer rates. From January to June 2020, we used the Discharge Planning Management System and the Ministry of Health and Welfare Care Service Management Information Platform to collect data. We analyzed (for the period January 2018 to December 2019) major barriers to long-term care implementation and established strategies for its implementation, such as revising discharge planning services to connect them with community-based long-term care services. Departments can publicize and arrange discharge preparations to link them with community-based long-term care service education and training, establish discharge preparation service seed personnel in wards, set up a community long-term care center, and formulate a performance reward system. The discharge planning application rate was increased from 36.7% to 66.7%, and the repeated assessment rate dropped from 4.27% to 0%; furthermore, the long-term care service transfer rate was increased from 284 to 306. Discharge planning services are used to connect community long-term care services and hospital services, and through the use of individual management models such as community bases and health management, allowing people to age locally and achieve the goal of sustainable hospital services.