醫療體系推行醫養合一政策初探：以某榮民體系為例

Exploring the integration of medical care and nursing home care po1icy in a healthcare system – Experience from a Veterans System

楊欽榮(Ching-Jung Yang)

指導教授 ： 鍾國彪

國立臺灣大學/公共衛生學院/健康政策與管理研究所/碩士(2021年)

https://doi.org/10.6342/NTU202104063

摘要

背景：臺灣人口老化快速，造成長期照護需求持續提升，因此長期照護之議題也越來越受到社會各界的關注。臺灣醫院漸漸往體系化發展，並開始涉足長照產業，推動醫養合一政策。而國內目前醫養合一之研究數量較為有限，且著重於政策執行與評估，並未針對醫療體系間各級機構之合作機制深入探討。因此本研究期望蒐集醫療體系各級人員之觀點，深入探討醫療體系推行醫養合一政策相關問題。
目的：本研究期望探討醫療體系推行醫養合一政策所遭遇之困難、醫療體系推行醫養合一政策之實質的影響、醫療體系推行醫養合一政策與醫療照護需求間的落差等問題。
方法：本研究為了解醫養合一政策制定者與執行者之觀點，故採用質性研究進行研究設計，以半結構式訪談概念，設計符合研究目的之訪談大綱，選擇某榮民體系之醫學中心、區域醫院、地區醫院、長照機構相關人員，進行個人化深度訪談法。再以內容分析法將訪談逐字稿，使用Nvivo質性研究軟體進行編碼，產生意義單元，彙整受訪者訪談意見，進而逐一探討本研究之各項研究目的。
結果：本研究訪談4家醫院，2家長照機構，共20人。彙整受訪者所提及醫療體系推行醫養合一政策可使用之策略歸納為醫療支援、行政支援、品質提升等三類。所遭遇困難為照護資源的受限、家屬溝通的困擾、就醫處理的限制、人力資源的困境等四類。實質影響歸納為政策優點、政策缺點、正面影響、負面影響等四類。政策與醫療照護需求間落差歸納為政策推動、政策整合、政策溝通等三類。政策建議歸納為醫療照護的建議、管理制度的建議、人力資源的建議等三類。
結論：本研究發現該醫療體系與一般長照機構遭遇之困難相同之處為照護資源的受限、家屬溝通的困擾，不同之處則為就醫處理的限制、人力資源的困境；另外在醫療體系推行醫養合一政策之實質影響方面，政策優點被提出之項目遠高於政策缺點，正面影響被提出之項目亦遠高於負面影響。在醫療體系推行醫養合一政策與醫療照護需求間落差之部分，主要為政策整合、政策溝通的問題。

關鍵字

長期照護 ； 醫療體系發展 ； 醫養合一 ； 整合式照護 ； 服務轉銜模式

並列摘要

Background：Rapid aging of Taiwan’s population has continously increased the demand for long-term health care. The issue of long-term health care has attracted more and more attention from all fields. Hospitals in Taiwan have been gradually systemmised, begun to get involved in the long-term health care business and implement the policy of integrating medical care and nursing care. However, the current domestic research on the integration of medical care and nursing care is limited. It focuses mainly on policy implementation and evaluation, yet less profound discussion on cooperation mechanisms between institutions at all levels in medical systems. Therefore, this study hopes to collect different points of view from all levels of medical systems and discuss issues related to the implementation of a medical care integration policy in medical systems.
Purpose：This research hopes to discuss difficulties encountered by medical systems in implementing a medical-care integration policy, substantial impacts on implementation of a medical-care integration policy in medical systems and a gap between implementation of a medical-care integration policy and real demands of medical care.
Method：This study aims to understand viewpoints of policymakers and implementors of medical care integration. A qualitative research method with the concept of semi-structured interviews has adopted to design outlines for interviews. The interviewed subjects of this research are employees from certain veteran system institutions including medical centers, regional hospitals, district hospitals and long-term care institutions. Then, we use Content Analysis to code interview transcripts with Nvivo software to generate meaning units, summarize interview opinions of the interviewees and discuss various research items of this study one by one.
Results：This study has totally interviewed 20 employees of medical workers from 4 and 2 parental care institutions. The medical-care integration policy can be summarized into three categories: medical support, administrative support and quality improvement. There are four types of difficulties which we encountered: limitation of care resources, communication problems with patient’s family members, limitation of medical treatments and dilemma of human resources. Substantial impacts are summarized into four categories: policy advantages, policy shortcomings, positive impacts and negative impacts. The gaps between policy and medical care needs can be summarized into three categories: policy implementation, policy integration and policy communication. Policy suggestions are summarized into three categories: suggestions for medical care, management systems and human resources.
Conclusion：This study finds out that medical systems and general long-term care institutions have encountered same difficulties of both limitation of care resources and communication issues with patient’s family. On the other hand, limitation of medical treatments and the dilemma of human resources are different. About the substantive impacts on implementation of the medical-care integration policy, advantages of the proposed policy far outweigh shortcomings of the policy itself. The proposed positive impacts are also much higher than the negatives. There is also a gap between implementation of the medical care integration policy in medical systems and demands for medical care, mainly for policy integration and policy communication.

並列關鍵字

long-term care ； medical system development ； integration of medical and nursing home care ； integrated care ； service transfer model

參考文獻

Brown, M. M. (2018). Transitions of care. In Chronic Illness Care (pp. 369-373). Springer, Cham. https://doi.org/10.1007/978-3-319-71812-5_30

一、英文文獻

Abraham Kaplan（1943）．Content analysis and the theory of signs．Philosophy of Science，10，230–247.

Angen, M. J. (2000). Evaluating Interpretive Inquiry: Reviewing the Validity Debate and Opening the Dialogue．Qualitative Health Research，10（3），375-95.

Arendts, G., Quine, S. Howard, K. (2013). Decision to transfer to an emergency department from residential aged care: A systematic review of qualitative research. Geriatrics Gerontology International, 13(4), 825-833. doi:10.1111/ggi.12053