醫學中心於出院準備轉銜長照服務之現況與挑戰

因應高齡化社會與慢性病年輕化，需要長期照護與慢性醫療之人口增加，醫學中心之就診族群，以急重症、多重慢性病或具複雜醫療需求病人居多，需要透過完善的出院準備服務，協助病人獲得出院後持續性照護，達到更優質的醫療照護品質。近年來隨著長期照護政策推展與滾動式修正，除了提供更多元的資源服務，出院準備服務團隊除了擔負長照2.0服務的評估功能，需整合醫療照護、長期照顧及社會福利等相關資源，透過持續性溝通協調，達到轉介與協助病人及家屬選擇最適切的照護資源。執行過程常需因應案況變化及案家選擇，持續調整服務計畫，因此執行過程也面臨許多挑戰與困境。本文旨於分享醫學中心執行出院準備轉銜長照服務之現況與臨床挑戰，希冀提供臨床實務與政策擬定之參考。

關鍵字

高齡化社會；長期照護；出院準備服務；持續性照護

並列摘要

Because society is aging and because an increasing number of patients are diagnosed as having chronic disease at a relatively young age, the proportion of the population that requires long-term care and chronic medical treatment has been increasing. Most patients in a medical center have been diagnosed as having acute or severe illnesses, multiple chronic diseases, or complex medical requirements. By implementing comprehensive discharge planning services, we can help these patients receive care after discharge and improve the quality of medical care that we provide. Recently, the type of resources for chronic care and long-term care has increased due to the implementation and continual revision of long-term care policies. The function of the discharge planning service team was not only to assess patients' long-term 2.0 care service requirements but also to integrate resources in areas such as medical care, long-term care, and social welfare. Through frequent communication and coordination, we can assist patients and their families in choosing the most appropriate care resources. The process often requires continual adjustments of the plan in response to changes in patients' conditions and choices. The purpose of this article is to share the status and clinical challenges of discharge planning in transitioning to long-term care services in the medical center. Our findings will be useful for clinicians and policymakers.

並列關鍵字

aging society ； long-term care ； discharge planning services ； continuing care

參考文獻

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Gonçalves‐Bradley, D. C., Lannin, N. A., Clemson, L. M., Cameron, I. D., & Shepperd, S. (2016). Discharge planning from hospital. Cochrane Database of Systematic Reviews, (1).

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