公私協力觀點探討社區整體照顧服務體系之推動—以臺中市大甲區為例

社區整體照顧服務體系是長期照顧十年計畫2.0十七項服務其中一項，本研究目的旨在運用協力治理角度，觀察該體系中協力之發生及何種因素會對該協力造成影響，並進而分析公私部門在當中可從事的角色任務及所受之影響為何。依據該研究目的，本研究採用質性研究，並以立意取樣及深度訪談法，擇參與臺中市大甲區社區整體照顧服務體系運作之公私部門成員共計8位進行訪談。研究發現，在照顧管理方面之協力，主要由地方政府長期照顧管理中心（簡稱照管中心）和社區整合型服務中心(簡稱A級單位)作分工，但複合型服務中心(簡稱B級單位)和巷弄長照站(簡稱C級單位)居中亦扮演不可或缺的角色。而同是長照服務提供者的A級單位被政府賦予為個案擬定服務計畫一職，並未完全獲得體系成員認同，因當中存在派案公平性之疑慮。此外，照管中心實施監督時，若能先與A級單位建立共識再要求遵守，較有助於良好協力關係之發展；以及A級單位辦理跨專業照顧會議尚有精進空間。在服務資源網絡建構方面之協力，A、B、C各級單位之間有不同的協力重點，其中又以B級單位對C級單位的協力事項最多。在協力初期時，部分成員過去合作背景有助於發展信任關係之外，在中間協力過程，A級單位採中立的態度擔任領導、建立多元的溝通對話平台、明確網絡成員的分工，並營造友善的團隊氣氛，加上主管機關適時參與其中，皆有助於彼此在互信基礎下發展協力關係；而經由協力運作之後，若有機會使彼此資源發揮互補功能，從中感受與認同該體系存在之價值，並持續其利益社區的使命感，進而對於未來服務產生願景時，將有助於該協力過程導向一個良性循環。至於在協力過程中，倘公部門本身對該體系成員之角色任務看法不一、補助經費核撥緩慢、補助資源配置採齊頭式平等、對某些協力項目挹注資源不足、對體系成員採用之稱謂具層級意味，以及政策不穩定時，皆有可能會對該協力關係造成負面影響。又體系內部具有公、私部門成員時，宜留意彼此行政與資源存在差異性，方能減少磨合；此外，成員在檯面下出現不同聲音、對某些服務認知不一致，乃至彼此存在競爭或比較關係時，亦有可能損及協力關係之發展。地方政府在該協力過程中可扮演政策引導、政策宣傳、促進參與、行政輔助、專業輔導、績效監督乃至照顧管理等角色，至於該體系成員，除了在社區中扮演主動發掘個案、帶動社區服務資源發展以及培育社區長照服務相關人員等角色之外，可進一步作政策倡導者。又在此一網絡互動情境下，地方政府不僅要決定本身參與運作程度，亦須額外投注行政成本，視情況以層級關係取代夥伴關係，同時對政策走向保持關注。而該體系成員雖能藉由協力發展出更完善之服務，惟本身亦需挹注不少資源，並受政策不穩定影響，陷入進退兩難局面。基於以上研究結果與發現，分別對於政府單位和民間單位提出以下建議：一、政府單位：（一）中央政府：廣納利害關係人意見，據以評估照管中心和A級單位分工之適當性；培訓專家學者並成立資料庫，俾供地方政府結合推動；調整經費補助設計；制訂協力單位考核與退場機制；以及加強政策穩定性等。（二）地方政府：透過教育訓練，促進體系成員對政策有完整認知；協助A級、B級單位建立完整跨專業團隊合作模式；拿捏好夥伴關係和監督關係；與中央政府研議有效率的行政流程；配置足夠的行政資源。二、民間單位：加入體系前做好額外付出之準備；籌組階段將各單位專業背景和過去合作歷史納入考量；網絡協調者以中立態度經營夥伴關係；透過溝通協調和明確分工讓體系運作上軌道；藉由資源分享讓成員感知合作的利益，以理解和尊重處理成員的分歧；加強與政府單位溝通，扮演政策倡導者角色。

關鍵字

公私協力；社區照顧；社區整體照顧服務體系

並列摘要

Comprehensive community care system is one of the 17 services covered in the 10-Year Plan for Long-Term Care 2.0. The objective of this study was to adopt a collaborative governance perspective to observe collaboration in the care system, explore factors affecting the collaboration, and further analyze the roles of public and private sectors in the collaboration and how their roles may be respectively affected. Driven by this objective, this study employed a qualitative approach and applied purposive sampling and in-depth interview methods. From the public and private sectors involved in comprehensive community care system of Dajia District, Taichung City, this study recruited eight members for interview. Results showed that the collaboration over care management is mainly based on division of labor between the local government’s long-term care management center (hereafter referred to as Care Management Center) and integrated community services centers (hereafter referred to as Class A Unit), but complex service centers (hereafter referred to as Class B Unit) and long-term care lane stations (hereafter referred to as Class C Unit) also play indispensable roles in the collaboration. Class A Units, which are also providers of long-term care, are assigned the task of making service plans for care subjects. However, this policy is not completely supported by all members of the system due to the concern for fairness in case assignment. Besides, there could be better collaboration if Care Management Center builds consensuses with Class A Units before demanding policy compliance. Moreover, the inter-disciplinary care meetings held by Class A Units could be further improved. In the collaboration over construction of a service sources network, Class A, B, and C Units have different focuses, with Class B Units responsible for comparatively more collaborative tasks with Class C Units. In the early stage of collaboration, some members’ past collaboration experiences could contribute to development of a trust relationship. In later collaboration, Class A Units would act as an impartial leader, build multiple communication platforms, implement division of labor among members in the network, and create a friendly team atmosphere. Besides, adequate involvement of the competent authority in the collaboration has also facilitated the development of partnerships on the basis of mutual trust. Members could perceive and more identify with the value of the system when resources are effectively used through collaboration. They would have a sense of mission for the community and develop visions of future services, which could lead to a positive cycle of the collaboration. During the collaboration, inconsistent views of the roles of members, delayed approval and appropriation of subsidiary funds, implementation of formal equality in allocation of subsidiary resources, insufficient allocation of resources for certain collaborative items, use of hierarchical titles for members, and policy instability may all cause a negative effect on partnerships. When there are members from both public and private sectors in the system, differences in administration and resources should be particularly noted and addressed to avoid conflicts. In addition, a public-private partnership might be negatively affected when members voice differing views in private, have inconsistent perceptions of certain services or are in a competitive or comparative relationship. The local government can take on the roles of a policy guide, a policy promoter, a facilitator of participation, a provider of administrative support, a provider professional counseling, a supervisor of performances, and a manager of care services in the collaboration. As to members of the system, in addition to the roles of discovering care subjects, driving community service resources development, and preparing community care workers, they can further act as a policy promoter in the community. In this context of network interaction, the local government needs to determine their level of involvement in the collaboration and also make additional administrative effort to replace hierarchical relationships with partnerships and pay continuous attention to policy development. Although members of the system are able to offer more comprehensive services through collaboration, they need to shift considerable resources to support the collaboration and are subject to policy instability, which often put them in a dilemma. Based on the above findings, this study provided suggestions to public sectors and private sectors as follows: 1. Public sectors: (1)The central government: Consider opinions from a wider range of stakeholders in evaluation of the adequacy in the division of labor among Care Management Center and Class A Units; offer training to scholars and experts and build a database which can be utilized by local governments in policy implementation; adjust the allocation of subsidies; develop an assessment and withdrawal mechanism for collaborative units; strengthen policy stability. (2)Local governments: Use education training to ensure comprehensive knowledge of policies among members of the system; assist Class A and Class B Unites to develop an inter-disciplinary collaboration model; draw a clear line between partnerships and supervisor-supervisee relationships; work with the central government to improve the efficiency of administrative processes; allocate sufficient administrative resources. 2. Private sectors: Be prepared for additional costs before entering the system; consider the background and past partnerships of each unit in the preparation stage; the network coordinator should manage partnerships with a neutral attitude; put the system on track through communication, coordination, and effective division of labor; increase members’ perception of the benefits of collaboration and understanding of conflicts through resources sharing; reinforce communication with government sectors and act as a policy promoter.