個案管理師於糖尿病共同照護中扮演之角色與功能

全球每年有380萬人死於糖尿病相關疾病，每10秒鐘就有1人死於糖尿病相關疾病；同時間（每10秒鐘）有2人新診斷出患有糖尿病，顯見罹患糖尿病之病患數正在快速增加中。聯合國於每年的11月14日訂為世界糖尿病日，國際糖尿病聯盟並發起「為糖尿病而團結（Unite for Diabetes）」運動，希望引起人們對糖尿病嚴重性的關注，同時鼓勵人們以具體行動對抗這種盛行的疾病。我國於2001年間，便透過「糖尿病共同照護網（Diabetes Shared Care Network）」提升及改善我國糖尿病病患之照護，惟施行迄今，有許多制度，包含但不限於試辦方案、糖尿病病患收案管理、轉診等制度，似有不合時宜之情狀，尚待修正之。惟制度之修正與調整，應如何為宜？本文作者認為，應深入瞭解第一線醫療照護提供者之觀點，方得知制度如何貼近實務的醫療操作。本研究以深入訪談法為研究基礎，訪談於醫療院所從事糖尿病共同照護的個案管理師，共訪談九位個案管理師，訪談期間自民國2019年3月22日起至民國2019年10月2日止，以瞭解個案管理師所認為之糖尿病個案管理師在共同照護中應扮演之角色與功能，以及其對於現行制度於運作時所面臨問題之觀點。研究結果發現，糖尿病個案管理師在共同照護中扮演的角色包含：確認並協助解決病患照護問題的決策者、病患照護的協調與轉介者與衛教諮詢者；個管師在糖尿病共同照護中面臨的問題有：人力多重運用的窘境、不同層級的醫療院所資源分配不均，共同照護模式無法普及到各醫療院所、缺乏統一的糖尿病照護品質監控制度。故本文建議能有護理領域之團隊協助規劃一套完整的個管師實務規範，以確保個管師的角色和功能之獨特化以及專業化。建立專科與一般科醫師之間的協同合作機制，提升基層醫療之糖尿病照護品質。讓「糖尿病共同照護網」發揮最佳的效用。

關鍵字

糖尿病共同照護網；糖尿病個案管理師；照護模式；訪談法

並列摘要

Globally, 3.8 million people die of diabetes-related diseases every year, with one death and two new cases every 10 seconds, and the number of people with diabetes is increasing rapidly. World Diabetes Day is celebrated each year on November 14 at the United Nations, and the International Diabetes Alliance (IDA) has mounted the “Unite for Diabetes” campaign, aiming to draw attention to the seriousness of the disease and encourage concrete action against its prevalence. In 2001, the Diabetes Shared Care Network was established in Taiwan to improve the care of patients with diabetes. However, in many systems, including but not limited to pilot programs, diabetic patient management and referral was outdated and required revision. Regarding appropriate revisions and adjustments, the author argued that a deeper understanding of frontline healthcare provider perspectives was imperative, to determine how systems fit into medical practice. This study used an in-depth approach to interview nine personalised case managers (PCMs) involved in diabetes shared care in medical facilities, between March 22 and October 2, 2000. The interviews were conducted to learn about PCM perceptions of their roles and functions in shared care and their perspectives on the problems the current system faces in its operation. Based on the findings, the problems PCMs faced in shared care included the dilemma of multiple uses of case managers, the uneven distribution of resources among different levels of medical facilities, and a lack of a unified quality control system for diabetes care. Therefore, it was suggested that a team of nursing professionals should participate in the planning of a comprehensive code of practice for PCMs, to ensure the uniqueness and professionalism of their roles and functions. A collaborative mechanism can be established between specialists and general practitioners, to improve the quality of diabetes primary care, thus improving the utility of the “Diabetes Shared Care Network.”