比較使用居家護理服務之社區及機構老人的醫療服務利用情形

研究背景：伴隨著快速的人口老化，老年人的醫療資源與長期照護需求逐漸增加。居家護理服務為提供疾病嚴重程度較高、有技術性護理需求的失能對象，但使用者可能因為服務模式的不同而造成醫療利用結果的差異。相較於入住機構，居住在家中可以支持老人走向在地老化的目標，且有較低的照護成本。然而我國過去的研究中並沒有針對不同服務模式其醫療利用結果差異探討，僅針對單一項長照服務的醫療利用結果進行分析。本研究希望透過比較使用居家護理服務的社區及機構老人在醫療利用結果的差異，提供未來長照政策發展不同服務模式的研究參考依據。研究方法：本研究使用全民健康保險資料庫之2010年百萬承保歸人檔，篩選出2003至2012年間首次使用居家護理服務且連續使用3個月以上的老人作為研究對象共3117人，依健保申報的案件類別不同可分為社區(居家照護)1667人、及機構(護理之家照護、安養、養護院民之居家照護) 1450人。研究以卡方檢定、皮爾森相關係數分析、兩組樣本T檢定、單因子變異數分析進行研究變項及結果變項之雙變項分析後，再使用複羅吉斯迴歸分析與複迴歸分析進行多變項分析，比較不同長照服務模式的老人在開始使用居家護理服務3個月後的ㄧ年間門診、急診、住院之利用情形。研究結果：在控制其他人口學因子後，社區老人每人年門診次數較機構老人少6.31次、每次門診費用多1196.9點、累積門診費用多21496點；發生急診相對風險多1.612倍、急診次數多0.41次、每次急診費用多1347.66點、累積急診費用多4586.77點；住院次數少0.21次、累積住院天數少3.44天。其餘醫療利用指標則無達統計上顯著差異。討論：社區老人及機構老人在住院使用並無顯著差異，顯示居住在家中的照護結果並不亞於機構式照護，對於造成重症需求的住院利用結果是相似的；雖然社區老人有較高的門急診利用情形，可能表示我國居家護理服務的收案條件過於嚴格導致居家護理服務在社區中普及程度較差，且基本醫療照護不足的情況使得社區老人的醫療可近性較差。此外，本研究亦發現醫院附屬的型態對長照服務的醫療利用結果有調節作用，相較於獨立型態的居家護理單位，使用醫院附屬的居家護理單位可減少的較多的門急診利用情形；機構老人則無此保護作用。可見居家護理師若有醫院的專業照護團隊作為支持，可以有較好的照護結果。結論與建議：本研究建議政府應重新審視居家護理服務的收案條件是否過於嚴格，應放寬收案條件使得社區中的失能老人能獲得適當的照護；現行居家護理服務應增加醫師及護理的訪視次數，以改善居家失能老人其基層醫療照護不足的問題；且未來長照政策應將居家護理及居家服務加以整合，才能發揮居家式照護的最大效益。此外，應鼓勵醫院拓展居家護理服務，可降低醫療系統的財務負擔，並且使後端的醫療資源得以有效利用。

關鍵字

居家護理；護理之家；機構式照護；醫療服務利用；健保資料庫

並列摘要

Background: With a rapid aging of population, needs of medical resources and long-term cares from older adults are increasing. People who received home care nursing services have needs for skilled-nursing care. Their healthcare service utilization may be different because they were in different long-term care models, communities or institutions. Compared to institutions, living at home could support older adults aging in place with a lower cost of care. However, there was no research about comparing healthcare service utilization between those who were in different long-term care model. This research aimed to compare healthcare service utilization between older adults using home cere nursing service who were in communities and who were in institutions. Methods: Data were extracted from 2010 National Health Insurance Claim Dataset. We examined those subjects who used home care nursing services at least 3 months during 2003-2012 and follow-up their healthcare service utilization for a year after they were first time admitted to long-term care. A total of 3117 older adults who used home care nursing services were included for analysis and the sample coud be separated 1667 communities older adults from 1450 institutions older adults. The main outcome variables examined were the use of outpatient service, emergency service, and hospitalization related services uses. The outcomes were compared between communities older adults to institutions older adults, using Chi-square test, Pearson’s correlation coefficient, two sample T-test, ANOVA, multiple logistic regression analysis and multiple linear regression analysis. Results: After controlling the demographic factors, the regression analysis showed that older adults who used home care nursing services had 6.31 fewer outpatient visits, 1196.9 points more expenditure of per outpatient visit, 21496 points more expenditure of accumulated outpatient visit, 1.612 times more risk of emergency department admission, 0.41 more emergency visits, 1347.66 points more expenditure of per emergency visit, 4586.77 points more expenditure of accumulated emergency visit, 0.21 fewer hospital admissions, 3.44 days fewer accumulated length of stay than older adults who lived in institutions in a year. Discussion: The hospitalization related service showed no significant difference between older adults who lived in communities and institutions. It indicated that the care outcomes of communities were as good as care outcomes of institutions. Though older adults who used home care nursing services living in communities had higher outpatient and emergency use, it may indicate that the inclusion criteria for older adults applying home care nursing service was too strict so that older adults living in communitis couldn’t get enough care resources. Bad accessibility to outpatient visit for older adults living at homes is another reason, too. We also found that hospital-based home care nursing agencies led to fewer outpatient and emergency use than non hospital-based home care nursing service. It could be that home care nurses who had the support from their hospitals could give better home care nursing services, and therefore their patients could show better care outcomes. Conclusion: This study suggested that the governments should reexamine the inclusion criteria for home care nursing service and increase the number of home care visits in order to improve the accessibility of outpatient visits for disabled older adults living at homes. Furthermore, future policy of long-term care should aim to integrate home nursing care and other home service so as to maximize the benefits of home care service. In addition, we encourage hospitals to expand home care nursing service in order to reduce the financial burden on the health care system and make good use of medical resources.