台灣長照十年計畫服務對身體功能之影響

研究背景與目的：人口快速老化是世界的共同趨勢，老年人口的比例與數量正不斷地攀升，導致失能人口及其長期照顧需求急遽增加中。發展居家與社區式的長照服務以支持在地老化、以及維持老年人的身體功能，是國內外許多已開發國家的共同目標。我國亦大力推行長照政策以回應老化需求，投入大量資源建構居家與社區式長照體系。近期關於居家與社區式服務成效的研究，開始注意到多元服務使用的重要性與影響，且整合多元服務也開始成為許多國家政策推行的方向。然而過去探討不同服務組合使用成效的研究，僅有探討對機構入住風險的影響。因此，本研究欲以長照十年計畫的資料，探討居家與社區式服務的不同服務使用組合、以及多元服務使用（使用類型數）對身體功能的影響。研究方法：本研究使用次級資料進行縱貫式研究。資料來自衛生福利部長照1.0政策下的照顧服務管理資訊平台，並串聯衛生福利資料科學中心之健保資料庫，分析2010至2013年間開始使用服務之個案半年後身體功能改變情形，共計篩選32,392人。以潛在類別分析將使用者依服務使用狀況分成四種服務組合；並以多變項複回歸分析，了解控制傾向、能用、需要因子後，不同長照服務組合、以及使用長照服務類型數，對身體功能ADL、IADL的影響。並進一步分成重度失能與輕中度失能兩組做分層分析。研究結果：在服務組合方面，服務使用可以分成以幾乎僅使用居家個人照顧服務為主的居家生活組(55.99%)、以使用居家護理及復健為主的居家醫療組(12.13%)、同時組合居家個人照顧服務及居家護理復健一起使用的居家混合組(27.40%)、及以日照及喘息服務為主的社區式服務組(4.48%)。使用居家混合組在ADL或IADL改變的結果皆最佳，而社區式服務組則整體最差。進一步以失能程度分層，則可發現仍以混合組最好，而在重度失能者中居家醫療組的IADL改變較居家生活組好(p=0.0263)，不過在輕中度失能者中卻是居家生活組較好但未達顯著(p=0.0574)。在服務使用類型數的部分，使用越多種服務者，IADL改變情形越好(p<.0001)，但對於ADL的改變情形則無顯著影響，進一步做分層分析，則發現重度失能者使用越多種服務者，ADL改變情形顯著越好(p=0.0038)；但在輕中度失能者則是使用越多服務ADL改變情形顯著越差(p=0.0408)。結論：居家混合服務的使用，對於半年後身體功能改變有最好的影響；服務使用類型數也是越多對身體功能越好。建議政策持續推動整合服務的使用。不過醫療專業服務有其重要性，尤其是針對重度失能者，而若能搭配居家個人服務同時使用則成效最佳。值得注意的是社區式的服務對於身體功能的影響則相對較差，建議未來日照能增加以促進功能為目的之介入、或加入醫療專業服務，並嘗試搭配居家式服務組合使用。另外研究也發現，失能程度較輕者，可能不需要太多項服務的混合使用。

關鍵字

長照服務；居家與社區式；服務組合；身體功能； ADL ； IADL

並列摘要

Background: The fast increasing aging population results in rapid increased long-term care needs. Developing home- and community-based services (HCBS) to support people to age in place and maintaining older adults’ physical function are common goals for many economically developed countries. Taiwan responded to the fast-increasing long-term care needs of its aging society with a National 10-Year Long-Term Care Program (TLTCP1.0), which includes HCBS. The TLTCP 1.0 began in 2007, with the TLTCP 2.0 implemented in 2017. More recent studies have begun to note the impact of use of multiple services, which is important given that prescribing multi-HCBS integration is current policy in many countries. However, most past studies exploring the effect of patterns of multiple HCBS use have focused on their impact on nursing home admission. Therefore, the current study aimed to explore the impact on older adults’ physical function of both (1) different HCBS use patterns and (2) number of HCBS types used. Methods: We used secondary data to conduct a longitudinal study. The cohort data were drawn from the TLTCP 1.0 database and from the National Health Insurance claims data. Our study analyzed changes in physical function among adults aged 65 and older before and after using TLTCP services for 6 months during the years 2010 through 2013 (N = 32,392). Latent class analysis was used to identify subgroups with different HCBS use patterns. We used multiple regression analysis to investigate the impact of (1) different patterns of HCBS use and (2) the number of types of HCBS use on change over time in disability related to activities of daily living (ADLs) and instrumental activities of daily living (IADLs), with predisposing, enabling, and need factors controlled. We also stratified our analysis by respondents’ levels of disability. Results: Four HCBS use patterns were identified: (1) a home-based personal care (home-based PC) group that used home personal care services only (55.99%), (2) a home-based medical care (home-based MC) group that used home nursing care and home rehabilitation services (12.13%), and (3) a home-based combined services (home-based mixed) group using both home-based personal care and medical care services (27.40%), and (4) a community-based service group that used mostly day care center and respite services (4.48%). Older adults in the home-based mixed group had significantly more improvement in both ADL and IADL scores compared to adults in the other three groups, while the community-based service group almost regressed the most. In the stratified analysis of the severely disabled, the IADL outcome of the home-based MC group was better than the home-based PC group (p = 0.0263), but for the less disabled, there was no significant (p = 0.0574) between the two groups. We also found that the more types of HCBS were used, the better the improvement in IADLs (p < .0001), but no significant impact on the changes in ADLs was observed. A further stratified analysis revealed that for those who were severely disabled, using more types of services led to significantly better ADL outcomes (p = 0.0038), but for those with light to moderate disability, using multiple services seemed to lead to worse ADL outcomes (p = 0.0408). Conclusion: The home-based mixed group’s HCBS use pattern had the best effect on physical function after a half year of service use. The more types of services used, the better the physical function. The impact of community-based services on physical function was relatively poor. Based on these results, we recommend that long-term care policies continue to promote the use of multiple integrated HCBS that combine personal and medical care. As for the day care services, it is recommended that centers can increase medical services and interventions for the purpose of promoting functions, and try to use it in combination with home-based services. For older adults who are severely disabled, home-based medical services should be a priority, and the effect will be best if they are combined with home-based personal services. In addition, our study found that people with lower levels of disability may not need many types of services.

並列關鍵字

Long-term care ； HCBS ； service pattern ； physical function ； ADL ； IADL

參考文獻

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