居家服務領域跨專業團隊合作的運作模式探討─以高雄市為例

Trans-disciplinary modality for co-operation in the field of home services.－Based on Kaohsiung city.

蔡沛璇(Pei-Hsuan Tsai)

指導教授 ： 陳武宗

高雄醫學大學/人文社會科學院/醫學社會學與社會工作學系碩士班/碩士(2021年)

摘要

國內為落實在地老化的長期照顧政策理念，居家式服務成為優先發展之領域，隨著醫療端和長照端居家服務項目的擴充，多專業到家服務，也日趨多元與普遍化，同時，跨專業合作已成為國內外健康照護及長期照顧服務領域發展的新趨勢。但針對居家服務領域內在長照2.0下多專業導入的方式及影響因素為何？照顧管理專業間的分工與互動情形為何？是本研究欲探討的問題，故在此問題意識與背景下，本研究主要目的有：(1)瞭解居家服務多專業導入的方式及照顧管理人員間互動情形、(2)探討長期照顧政策與居家服務單位機構特性對多重專業導入的影響、(3)前瞻居家服務領域跨專業合作未來發展的行動計畫
本研究以高雄市為場域，採焦點團體為主，半結構式訪談法為輔，經查高雄市政府衛生局特約居家式長照服務機構名冊，共計5位居服單位主管、4位居服督導參與本研究。
研究結果為(1)居家服務領域的跨專業合作仍處多專業導入，各專業間接觸少且缺乏整合、(2)多專業導入具系統本位（異動通報）、專業本位（居家服務一條龍）及契約本位（低度多專業連結）的服務三方式、(3)居家服務督導是導入多專業的關鍵，個案管理師與照顧專員是執行多專業導入的要角、(4)案量的擴增及整合專業能力的不足，皆是影響照顧管理人力間互動的因素、(5)居家服務機構特性不同，導入多專業的模式不同。並據此提出以下建議：(1)發展醫療端與長照端的整合媒介、(2)提升多專業認知與整合協調能力、(3)建構有效的跨專業合作模式與教育訓練方案、(4)增加跨專業案例研討機會以強化多專業間對話、互動與連結、(5)建構跨專業合作資訊平台。

關鍵字：長照2.0、居家服務、照顧管理專業人力、多專業、跨專業團隊合作

關鍵字

長照2.0 ； 居家服務 ； 照顧管理專業人力 ； 多專業 ； 跨專業團隊合作

並列摘要

In Taiwan, home-based services have become a priority development area . With the expansion of medical and long-term care services at home, multi-professional home services have become increasingly diversified and universal. Meanwhile, transdisciplinary cooperation has gained traction in the development of domestic and foreign health care and long-term care services. However, what are the optimal methods and influencing factors of the introduction of a multidisciplinary approach under the Long-term Care Plan 2.0 in the field of home services? How is labor divided between care management professionals and how do they interact? These are the questions that this study seeks to explore. Therefore, based on an awareness of this issue and its background, the main objectives of this study are, first, to understand the ways in which home services are introduced in multiple disciplines, as well as the interactions between care managers. Second, it aims to explore the impact of long-term care policies and the institutional characteristics of home service units on the introduction of multiple disciplines. Third, it strives to explore the future of transdisciplinary cooperation in the home services action plan for development.
This study conducted focus group and semi-structured interviews in Kaohsiung City. Five supervisors in the home service unit and four in-service supervisors participated in this study.
First, the results showed that in the field of multidisciplinary services, home interdisciplinary cooperation is still provided. Further, they highlighted a decrease in professional contacts and a lack of integration. Second, the results identified system-based (change notification), professional-based (one-stop home service), and contract-based (low-level multi-professional connection) multidisciplinary service introduction methods. Third, home service supervision is the key to the introduction of multiple disciplines, and case managers and care specialists are instrumental players in implementing the introduction of multiple disciplines. Fourth, the expansion of case volumes and the lack of integrated professional capabilities are factors affecting the interactions between care and management personnel. Fifth, the characteristics of home service agencies are different. Such a difference was also found in the models for the introduction of multiple disciplines. The recommendations of this study include, first, developing an integrated medium for medical and long-term care. Second, it suggests improving professional integration and coordination capabilities. Third, it proposes constructing an effective transdisciplinary cooperation model and education and training program. Fourth, it propounds using transdisciplinary case study opportunities to strengthen multi-professional dialog, interaction, and connection. Finally, this study recommends building a transdisciplinary cooperation information platform.

Keywords: Long-term Care 2.0, home service, care management professional manpower, multi-professional, transdisciplinary team approach

並列關鍵字

Long-term care 2.0 ； home service ； care management professional manpower ； multi-professional ； transdisciplinary Team Approach

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