從醫療服務體系觀點探究我國急性後期照護服務之發展

背景：我國65歲以上老年人口在1993年到達7％，開始進入「高齡化社會」，2018年即超過14％，進入「高齡社會」，短短25年間我國的老年人口占率便暴增一倍，老化速率相較於其他國家更是成長飛速。整體醫療照護需求亦將隨高齡社會與日俱增，勢必對醫療健康照護體系的醫療資源帶來重大影響與衝擊。為控制醫療資源之耗用情形，促使醫療供給者有效率的提供服務，減緩醫療照護支出的成長，實施前瞻性支付制度（如DRGs）是國際趨勢。我國全民健康保險自2008年起分階段導入台灣版的DRGs支付基準，預測實施DRGs制度，將驅使醫院住院日數縮短及病床佔床率下降，急性後期或急性醫院出院後的健康照護需求勢必大幅增加。因此如何滿足國人對醫療照護服務的需要，並在有限的資源下，同時追求醫療照護服務之效率、效能、規模經濟、永續經營與創新價值，實有賴建構醫療體系相關政策之重新審視與革新，儘早完成急性後期照護之服務網絡與體制，以為因應。目的：本研究將從醫療服務體系觀點來探討我國急性後期醫療照護服務之發展脈絡，以及醫院病床資源之管理，供政府未來規劃相關政策或建立制度之參考。方法：本研究設計採用質性研究中的文獻研究法 (Archival Research method)。研究資料蒐集來源包含1.政府部門相關出版品或公開資料、施政計畫、補(捐)助或委託研究計畫成果報告、統計年報等；2.相關文獻及碩博士學位論文；3.相關研討會簡報及會議資料；4.網際網路搜尋相關資料等。並參考學者研究提出之概念上，可以分為A.資源、B.方案組織、C.服務提供、D.管理及E.經濟支持等元素之醫療體系觀點的研究架構，來初探我國急性後期照護之發展歷程。結果：研究結果分為二部分，一是查考國際上包含美國亞急性照護（subacute care）、急性後期照護 (Post-acute Care，PAC)；英國中期照護 (intermediate care)；德國中期照護 (intermediate care)；澳洲過渡性照護 (Transition care)，及日本恢復期復健照護(recovery phase rehabilitation care)等，各國均有發展急性住院後照護服務模式之經驗，可作為我國政策規劃之參考。第二部分則是探究我國醫療照護體系-急性後期照護之發展歷程，首先從衛生福利部醫政管理之醫療網計畫構面，回顧各期計畫對於急性後期照護發展之政策脈絡；次從全民健康保險之財務構面，回顧全民健保推動急性後期之政策發展；最後再從醫政管理之醫療體系對於醫院病床資源的管理構面，探討醫院病床與發展急性後期照護服務的相關性。結論：藉由本研究得以窺見我國發展急性後期照護服務之過去、現在及對於未來的展望。自2001年起醫療網第四期計畫，即提及並開始思考朝研議全民健保急性後期適切給付方案之方向規劃。2009年起第六期醫療網計畫至第七期醫療網計畫2016年，分別由退輔會、衛福部(醫福會及照護司)編列公務預算，著手策略性地推行亞急性（中期）照護的多元模式試辦計畫。中央健康保險署則自2014年1月1日開辦健保PAC計畫，規劃採分階段推動，執行迄今，僅針對腦中風、燒燙傷、創傷性神經損傷、脆弱性骨折、心臟衰竭、衰弱高齡病患等6項疾病別提供急性後期照護服務。參考國內外研究已有發現照護連續性可以提升照護結果並節省醫療費用。醫療服務體系間如何連結與合作，提高民眾醫療照護的完整性與連續性，是未來發展急性後期照護制度的重要方向。亟盼推動「第九期醫療網計畫」醫療體系面之醫政管理(包含醫療機構設置標準相關法規、醫院病床資源之調控與布建，急性醫療網絡等)之時，得與健保的財務支付制度，建立良好的政策整合與連結，並參考國際已執行多年急性後期照護服務的實務經驗，以及世界衛生組織國際功能、失能和健康分類提供Post-acute Care目標的框架，戮力於“以人為本”照護的核心價值，優化每個人的健康並實現他們獨特的可實現目標，來遂行及完善我國的急性後期照護服務體制。

關鍵字

急性後期照護；中期照護；醫療體系；醫療網

並列摘要

Background：Taiwan’s elderly population reached 7% in 1993, signifying that Taiwan entered into an "ageing society." It exceeded 14% in 2018 and Taiwan became an "aged society” since then. In just 25 years, Taiwan’s senior population has doubled; its ageing rate grows faster than other countries. An aging society increases overall healthcare demand and has a significant impact on healthcare resources. Implementing prospective payment systems, such as Diagnosis Related Groups (DRGs), to allocate medical resource, improve medical care efficiency, and reduce medical care spending growth, is an international trend. Since 2008, Taiwan’s National Health Insurance (NHI) has introduced the Taiwan DRGs payment system in phases. It is predicted that implementing Tw-DRGs will shorten hospital stays, lower occupancy rate, and thus increase the demand for post-acute care (PAC) and transitional care. Therefore, how to meet population’s needs for medical care with limited resources while pursuing the efficiency, effectiveness, economies of scale, sustainable operation and innovative value of medical care really depends on re-evaluating, innovating medical care policies and completing medical care system’s PAC network ASAP to respond to population ageing. Purpose：The purpose of this study is to explore Taiwan’s PAC development and bed management from medical care system perspective and can serve as a reference for government’s future policy planning or system establishment. Method：This research adopts the design of an archival research method in qualitative research. Sources of data collection include 1. Government publications, public information, policy plans, final reports of grants or commissioned research projects, annual statistical reports, etc.; 2. Relevant literature, theses and dissertations; 3. Related Seminar presentations and conference materials; 4. Internet search for related materials, etc. By referring to the concepts in academic research, this study explores the history of Taiwan PAC development from medical care system perspective according to the following framework: A. resources, B. program organization, C. service provision, D. management and E. economic support. Result：The results have two parts. The first part examined care transition internationally, including subacute care and PAC in the United States, intermediate care in the UK, intermediate care in Germany, transition care in Australia, and recovery phase rehabilitation care in Japan. All of the above-mentioned countries have experience in developing PAC models and can serve as reference for Taiwan’s policy formulation. The second part explored Taiwan medical care system’s PAC development. This study reviewed the information from three aspects. First is from Taiwan’s Medical Network Plan (MNP) aspect to review PAC policy development in each phase of the MNP. Secondly, is from financial aspect to review the NHI policy development to promote PAC. Finally, is from bed management aspect to discuss the relationship between hospital beds and PAC development. Conclusion：This study helps us understand the past, present and future perspectives of PAC development in Taiwan. Since the MNP Phase 4 in 2001, we began to formulate NHI reimbursement plans for PAC. From the MNP Phase 6 in 2009 to the MNP Phase 7 in 2016, the Veterans Affairs Council and the Ministry of Health and Welfare had jointly created strategic budgeting for a multi-model pilot program of subacute (intermediate) care. Since January 1, 2014, the NHI Administration has launched the NHI PAC plan in phases, providing PAC services only for patients with 6 types of disease: stroke, burns, traumatic nerve injuries, fragile fractures, heart failure, and debilitating elderly diseases. Domestic and international studies found that care continuity can improve health outcomes and costs. How to connect and collaborate within medical care system to improve care continuity gives important directions for future PAC development. It is hoped that MNP Phase 9 can promote better policy integration and linkages between medical affairs aspect of medical care system (healthcare regulations, national bed management, acute care network, etc.) and the NHI payment system, and to enhance Taiwan’s PAC system by devoting to the core values of People-Centered Care and to optimize personal health with customized goals after reviewing PAC policy implemented for years globally and WHO’s framework for PAC.

並列關鍵字

Post-acute care ； intermediate care ； medical system ； medical network

參考文獻

一、中文部分

Google Scholar

于保榮、王慶(2006)‧日本醫療保險診療報酬體制改革研究‧doi:10.14055/

Google Scholar

j.cnki.33-1056/f.2006.03.021‧檢自 https://kns.cnki.net/kcms/detail/detail.aspx?dbcode=CJFD dbname=CJFD2006 filename=WSJJ200603020 v=N2Df9oOHBkjqGgBtYiwltl9lZMEKZGxa7g3x9lD%25mmd2FLuGcqR4fsYFXUYuUi1eoeoet

Google Scholar

王允翬(2015)‧在全民健保之外──各國健康照護制度簡介‧陽明醫聲，VOL 21，https://ymmedmagazine.blogspot.com/2015/04/blog-post_11.html

Google Scholar

行政院經濟建設委員會(2009)‧長期照護保險制度初步規劃成果與構想‧台灣經濟論衡，特別報導，7(10)，12-32

Google Scholar

國際替代計量

從醫療服務體系觀點探究我國急性後期照護服務之發展

全文下載

主題瀏覽