某區域教學醫院推動全民健康保險家庭醫師 整合性照護試辦計畫之成效探討

Approach to the Achievement of Integrated Health Care Trial-Run Plan

呂 靜 儀(Jing-Yi Lu)

指導教授 ： 李弘暉

元智大學/管理學院/管理研究所/碩士(2007年)

摘要

社區醫學應屬於全人、全家、全社區的健康照護，透過衛生教育讓社區民眾改變觀念，接受「以家庭為單位的醫療服務」，建置一個社區共同照護網絡。全民健康保險家庭醫師整合性照護試辦計畫其目的為建立家庭醫師制度，提供民眾周全性、協調性與持續性的服務及以民眾健康為導向，建立以病人為中心的醫療觀念，提升醫療服務品質。
筆者於九十三開始承辦○○綜合醫院執行此試辦計畫之運作；現今與醫院共同參與此試辦計畫之診所共有34家，分別為：大樹、北桃、城中、康健及蘆竹社區醫療群。五個社區醫療群與醫院間的共同合作雖有訂定明確的機制及一些統計的數據，但從未做過詳細的資料整理及分析，透過此一研究報告，運用醫療品質的評估方法、家庭檔案與轉介系統的評估及及實際訪查方式，針對執行單位之計畫進行品質監控，以瞭解○○綜合醫院在推動全民健康保險家庭醫師整合性照護試辦計畫之成效及不足之處，作為持續推動此計畫改善之依據。
五個社區醫療群共收案23,584位家戶會員，而期望目標值為照護34,000位家戶會員；故仍有努力的空間；家戶會員的基本資料建檔完整，達成率為100％，能適時提供各基層醫療診所之家戶會員的人口學資料及疾病統計資料。○○綜合醫院提供單一窗口的轉診服務，社區醫療群基層醫療診所月平均轉介125.6位個案至醫院接受檢查或診治，佔該醫院轉診服務業務的25％。24小時緊急電話諮詢服務專線提供家庭會員緊急電話諮詢服務，計畫執行期間共接獲319通諮詢電話，其表示民眾的利用率較低，原因可能為宣導不足或家戶會員的需求性不高所致。
基層醫療醫師們因參與社區醫療群的運作，他們開始共同關心社區的健康議題、宣導健康及預防保健的重要性及參加預防保健的社區服務，更身體力行改變自己原本的生活方式。有關計劃評核指標中家戶會員指定率平均為14.34％，已達計畫規定的指標；但會員固定就診率平均為42.64％和預防保健達成率部分：子宮頸抹片受檢率21.56％，成人健檢率34.44％均為達評核指標之標準；其原因與參與家庭醫師制度推行的佔率有關，民眾仍有選擇就醫自由的權力。而健保局執行實地訪查結果，其成績均較健保局所公布之統計數據高，意指執行成效在一般水準之上。
社區醫療群與醫院間的醫療實務運作及策略聯盟的合作機制已建置並有其共識，但事實上為中央健保局輔導之試辦計畫，如新年度無計畫的經費補助及政策的支持，現行呈現之合作模式恐會因此而停滯。

關鍵字

家庭醫師整合性照護制度；社區醫療群；基層醫療

並列摘要

Community medicine is pertaining to every individual, family and the whole community. It establishes a jointly heath care network by means of the hygiene education to change people’s common conception in the community so as to accept the services by family as a unit. Based on the idea of National Health Insurance and family doctors, the goal of the trial-run plan of integrated health care & attendance is to establish a family doctor system, providing people a thoroughly, coordinated and persistent services. Hence, the conception of people-health-oriented and patient-treatment-centralized plan help to improve the quality of medical care.

The researcher began undertaking the implementation of OO comprehensive hospital trial-run plan in 2004. Up to now, there are a total of 34 clinics that jointly participate with this plan including the community medical care groups in DASHU, BEITAO, CHENGZHONG, KANGJIAG & LUZHU. In despite of the definitely mechanism and some database between the five community medical treatment teams and the hospitals, under the absence of the compiled database in detail and analysis, on this research report, we monitor the executive unit for quality control by means of the evaluation of medical quality, family database, transfer system and the real on-site visit, that helps us figure out the insufficiency of the trial-run plan of integrated health care & attendance so that the hospital can keep propelling & improving the plan.

A total of 23584 family members in five communities are covered by medical treatment teams and the anticipated target is 34000, therefore there’s room for improvement. The family member’s database is completed and the accomplished rate is 100% that can provide each primary medical clinic the family members with the demography and disease statistics report. OO comprehensive hospital provides the single window transfer services. The community medical treatment team transfer an average 125.6 cases per month to hospital for check-up or further treatment, which takes up 25% of transfer services in that comprehensive hospital. The 24-hour emergency line services provide the family members in the case of emergency. During the plan practices, there were only a total of 319 consulting phone calls; it means the usage rate tends to be low. The reason could be due to the lack of propaganda or the family members are not high in demand.

Owing to the participation, medical physicians joined in the practice of community medical team, they begin commonly concerning about the health issue in the community, propagate the importance of health and prevention of disease and then participate in the community service for health care. They also devoted themselves to change their living style for the community. Pertaining to the plan check criterion, the family member dominated rate is 14.34% in average which already reach the plan’s target. However, the member’s routine visit clinic rate is 42.64%. With regard to the prevention of disease, the cervical smear check rate is 21.56% and adult check-up rate is 34.44%; all reach the benchmark of plan check. That must have contributed to the result of the promotion of family doctor system. People still have the right of freedom to choose health care. According to Healthcare Bureau, the performance result from the real on-site visit is better than those shown on the publicized statistics. Therefore, the practice effect is higher than the average level.

The cooperation mechanism had established between community medical team and hospital in terms of medical operation and strategy alliance and they have come to a consensus of view about it. However, it’s the trial plan from Central Health Insurance Bureau. If it’s lack of the budget plan and strategically support for the next fiscal year, the existing cooperation model should be interrupted.

並列關鍵字

community medical team

參考文獻

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