長期照顧之居家服務輸送體系探究：一位照顧管理專員的視角

隨著近年來台灣人口的高齡化以及家庭結構的變遷，政府推出「長期照顧十年計畫」，以解決老年人的照顧問題。長期照顧十年計畫的立意是提供普遍性的福利服務，但是在實務中，仍然出現有照顧需求的家庭無法使用此福利的現象。研究者身為一個照顧管理專員，常對此現象感到不解與難過。本研究中，研究者試圖以執行長期照顧十年計畫的核心人物~照顧管理專員的觀點，針對居家服務輸送體系如何運作提出社會學的詮釋，包括理解照顧管理專員是如何執行其業務，從申請到最後的核定，照顧管理專員所依據的判予規定是甚麼？這些規定是從何而來？是甚麼樣的權力結構影響照顧管理專員的核定？為何某些民眾得以進入服務體系？某些民眾卻被拒絕在外？　　為了探討以上問題，研究者將採用「建制民族誌」研究方法。建制民族誌為女性主義社會學家Dorothy E. Smith所發展出的概念。她認為所謂客觀中性的知識創造，其實是以男性經驗出發的社會理論為基礎。這種表面上是客觀中性的知識創造，實際是性別權力不平等關係的複製過程。研究者認為建制民族誌著重組織中結構的權力運作，以及重視各種物質性的文本，相當適合身在組織中的人員進行對其工作的反思性研究。本研究共訪談17名人員。除了訪談居家服務輸送體系的核心人物照顧管理專員（7名）之外，研究者為了深入探究居家服務輸送體系的權力運作，另外訪談具照顧需求的家庭（7戶）、照顧管理督導（1名）、居家服務督導（2名）等，試圖將居家服務輸送體系的權力網絡呈現出來，並理解權力網絡的運作是如何影響居家服務輸送體系。　　以建制民族誌的觀點去重新理解之後，發現居家服務輸送體系其實是隱含且複製了「家庭應負擔照顧責任」及「社會福利只為補充性的性質」之性別化的意識型態，使得女性家庭照顧者的需求及處境被漠視；再加上「自付額」使用者付費的觀念，使得某些弱勢階級就算有服務需求也無法進入居家服務體系。國家認為照顧責任應為家庭承擔的意識形態，經由組織的規定及照顧管理專員與民眾的互動再生產，家庭需負擔照顧責任的價值觀便生生不息的在照顧體系中運作，形成了弱勢階級與女性持續被國家體制壓迫的情形。另一方面，照管專員的實際操作過程~「行政裁量」與「依法行政」，又反過來強化國家對「家庭需負擔照顧責任」的意識形態，並排除了不符合一般家庭樣貌的邊緣家庭，並辨認誰是「值得」被協助者，真正需要照顧的家庭反而被居家服務輸送體系抵擋在制度外。

關鍵字

長期照顧；照顧管理專員；建制民族誌；居家服務輸送體系

並列摘要

In recent years, due to the aging population and transformation in family structures in Taiwanese society, the government introduced the Long-term Care Program to solve the problem of caring for elderly. The program aims at providing a social welfare for elderly in general. Nevertheless, there are still some families in need can not use the resource. The researcher is a care manager and feels puzzled and sad about what I saw at work. In this dissertation, I will investigate home care delivering system in the Long-term Care Program, from the standpoint of a care manager, who plays important role in this program. I will ask the following questions: how does a care manager run their duties? What are the rules for verification? What roles do bureaucratic authorities play in the process? Why do some citizens have access to services but some are rejected? 　　To investigate above issues, the research adopts institutional ethnography as the method. The method was founded by Dorothy E. Smith who is a female sociologist. Smith believes the so-called objective knowledge is a theory based on the experiences of men. In fact, it duplicates gender inequality. Institutional ethnography focuses on experiences of the people involved, exercises of power in the organization, and documentation. It is therefore suitable for a reflective research of a staff who works in the organization. 　　In this research, I interviewed seventeen people. Experiences of seven care managers are the main focus of the research. Moreover, to uncover the exercise of power in the home care delivering system, the researcher also interviewed seven families in need of services, one care supervisor and two home services supervisors. The goal is to present the power structures in the home care delivering system and to realize how the social hierarchy influences the system. 　　I discover that the home care delivering system implicitly duplicates the gender ideologies that home cares are the duties of families, and that the social welfare is just a supplement to that. In effect, the need and situation of female home care givers are ignored. Moreover, the user-pays principle results in the disadvantaged groups to be rejected to services even they are in need. 　　The government believes the ideology of home cares are the duties of families and utilizes the rules of organization and interaction among care managers and citizens. The idea that home cares are the duties of families will run growing continually in the care system. Disadvantaged groups and female carers are repressed by the government's policies. On the other side, the exercises of care managers are based on administrative discretion and administration by law. The processes reinforce the concept of home cares are the duties of families and eliminate the marginal families of non-general manner. As a result, these policies define who are deserved candidates but families in need of the services are excluded by the home care delivering system.