探討南台灣區域/地區級醫院參與 「家庭醫師整合性照護制度」之過程

Participating Process of Southern Taiwan's Regional/Area Hospitals in "National Health Insurance Pilot Project of Family Physician Integrated Care System"

蔣維宜(Wei-Yi Jiang)

指導教授 ： 張菊惠

長榮大學/健康科學學院/醫務管理學研究所/碩士(2006年)

摘要

中央健康保險局於民國92年提出「家庭醫師整合性照護制度」試辦計畫，為國內首度試圖將基層醫療與地區/區域醫院結合形成社區照護網。本研究以南台灣地區/區域醫院為研究對象，並以「歷程理論」洞察情境脈絡及其影響因素。本研究目的：一、探討醫院參與之情境脈絡，各歷程/階段中的影響因素，促成醫院參與的機制。二、探討合作關係面向與網絡結構特徵及其影響因素。三、探究參與過程對醫院帶來的影響與後續合作之意向。
採用半結構深度訪談收集資料，研究對象為民國93年10月參與之33間合作醫院。以加入年度與合作群數作為理論性抽樣依據，並輔以資料飽合度為原則，共計12間醫院完成訪談。以訪談逐字稿中發展核心概念，進行類屬分析並結合情境分析。
研究結果摘要如下：一、依據參與機制中的關切與外部機會條件，將參與型態區隔岀尋覓型、順勢型、引導型、媒合型。關係生成背景、誘因與代價之權衡以及醫院對外連結網絡，為醫院參與啟端之影響因素。二、合作關係呈現多重性與決策權力結構面向，而網絡結構具有為同質性、凝聚性與中介性/橋樑等特徵。醫院條件能力與利益評估考量項目之「再創新」（翻新轉診機制/重建資訊系統）、「風險」因素影響醫院投入資源的程度有所差異，並反映在合作關係之多重性；關係生成背景為外部機會介入進而參與計畫之醫院其決策權力式微，而網絡結構當中扮演中介性/橋樑之醫院其決策權力較為對等。三、合作結果分析歸納為樂意與失望，影響樂意的因素包括醫院內部利益評估之「可試驗」（落實社區理念）、決策權力的對等性，以及網絡結構具有標竿或中介性/橋樑特徵，其合作醫療群數量之增長呈現「緩增」或「遞增」；而影響失望的因素為決策權力的式微，以及網絡結構具有壞份子特徵，其合作醫療群數量之增長呈現「單一」或「劇增」。

關鍵字

家庭醫師整合性照護制度 ； 創新傳播 ； 社會網絡 ； 歷程理論

並列摘要

Bureau of National Health Insurance proposed the “Trial Plan for the National Health Insurance Pilot Project of Family Physician Integrated Care System” in 2003. It is the first attempt in the country to form a community care network by bringing together local medical facilities and area/regional hospitals. This research uses area/regional hospitals in southern Taiwan as subjects and employs process theory to scrutinize the situation and influencing factors. The purpose of this study is to: 1)investigate the circumstances under which hospitals join the system and the influencing factors in each process/stage, as well as the system enabling the hospitals to join; 2)discuss the direction of the cooperative relationship as well as the characteristics and the influencing factors of the network; 3)explore the impacts and effects of the participation on the hospital.
The study collected data by conducting semi-structured interviews with 33 participating hospitals, which signed on in October of 2004. Using the year the hospital joined and the number of hospital cooperating as theory-base sampling and using data saturation as a principle, interviews were conducted with a total of 12 hospitals. From the transcripts of the interviews, we developed concepts, underwent category analyses and combined scenario analyses.
The synopsis of the results is as follow: 1) According to the concerns in the participatory system and external opportunities, the manners of participation are categorized as seeking, going with the flow, leading, and match-making. Influencing factors of hospitals' participation include relationship forming background, balance of incentives and cost, and hospitals’ external communication network. 2) The cooperative relationship is multiplicity and decision-making power leaning. The network has characteristics of homogeneity, connectivity and bridge. Differences in factors, such as hospitals’ ability, reinvention (reinvent referral system/rebuild information system) considered by hospital in benefit assessment, and risk, affecting the amount of resources hospitals invest. The differences are reflected in the multiplicity of the cooperative relationships. Decision-making power is weak in hospitals where relationship-forming background is the external opportunity interference causing the hospitals to join. However, in hospitals where network structure plays the middleman/bridge, decision-making power is on equal footings. 3) Cooperation results can be categorized as willingness and unwillingness. Factors affecting willingness include trialability (following through with the idea of community) under hospitals' benefit assessment, decision-making powers being on equal footings, network structure having the characteristics of being a yardstick or bridge, and the number of participating medical facilities showing signs of gradual
increase. Factors determining unwillingness include weak decision-making power and characteristics of bad participants in the network structure. The number of participating hospital shows signs of being single or sharp increase.

並列關鍵字

Family Doctor Integrated Care System ； innovative communication ； social network ； process theory

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