醫療院所籌辦長照2.0社區整合型服務中心的經驗之研究：醫務社工主管觀點

隨著人口老化及健康照護發展方向的轉變，醫療體系在社區健康照護領域逐漸佔有重要的責任，醫療服務從被動轉為主動，從定點提供醫療服務轉化為與社區共存、提供在地醫療照護。醫療社區化的過程，醫務社工被賦予擔任打通醫院與社區連結的橋樑角色。醫院參與長照2.0 ABC服務體系運作的過程，使醫務社工主管與長照服務產生緊密的連結，也面臨及感受承接創新任務的困境與壓力。本研究以深度訪談的方式面訪6位分處公私立不同體系醫院的醫務社工主管，希冀透過其協助辦理長照2.0 A級單位的過程主觀經驗之整理，了解所面臨的困境及自我調適作為，以提供未來加入協助推辦A級單位的醫務社工主管實務上的建議。研究結果發現，醫務社工主管可從醫院新任務指派或啟動因素的考量、醫院長官支持態度與跨專業團隊運作等方面著力，減少面對新任務開展的困境。最重要的是醫務社工主管本身在協助辦理長照2.0 A級單位前，須提升自我社區能力、認同並堅定自我專業價值，善用倡議的角色及能力得到醫院主管的力挺，並落實跨專業團隊合作，才能針對長照服務使用者多元的需求進行個別性評估，以提供整合、連續性且適切的長照服務計畫。

關鍵字

社區健康照護；長照2.0 ；跨專業團隊；自我認同

並列摘要

With an aging population and the change of health care development, the medical system in the field of community’s health care takes a role in an important responsibility, the medical service has been transferred from being passive to active; from fixed point offering medical service to community’s co-existence, providing local medical care. The process of medical socialization, medical volunteers are given a role to bridge a connection between hospitals and communities. Hospital participates in the process of Integrated LTC 2.0 Community Service Center, making directors of medical social workers have a close connection with long-term care service, they also face and feel the difficulty and pressure of taking the new innovative duty. The study deeply interviews 6 directors of medical social workers in different private and public systems of hospitals, hoping to understand the difficulties we face and the practice of self-adjustment through the process of operating long-term care unit A from subjective experience, in order to provide actual suggestions for the directors who assist to hold unit A. Through studies, results show that the directors of medical social workers can lessen the difficulties of facing new duties by taking the new duties assigned by the hospitals or operation factors into consideration, the support attitude from hospitals’ executives and trans-professional teams operations. The most important is before directors of medical social workers assist to deal with long-term care unit A, he or she must raise the ability of self-community, recognize and persist self-professional value, make favorable use of suggestive role and ability to acquire the support from directors of hospitals plus lift up to reality of trans-professional teams corporations so that they can operate individual assessment toward users of long-term care with various need in order to provide integrated, continual proper long-term care service plan.