衛生所糖尿病、高血壓疾病管理模式成果評價

Effectiveness of Disease Management on Diabetes and Hypertensions' Patients in Health Station

劉慧俐(Hui-Li Liu) ； 李素華(Shu-Hua Li)

《健康促進暨衛生教育雜誌》 24期 (2004/12) Pp. 53-78

摘要

本研究整理八十六年度中央健保局高屏分局高雄市糖尿病、高血壓利用醫療資源者，依照里別將各戶籍地址資料予以區分，再轉介給各衛生所，依照利用次數高低，配合衛生行政中老年疾病防治作業，自八十八年三月至六月執行家庭訪視介入管理研究。研究共收案糖尿病、高血壓個案共321人，參與研究訪視之高雄市衛生所公共衛生護士共79人。
公共衛生護士居家訪視之321糖尿病、高血壓個案，以糖尿病居多，佔所有個案的 58.3%，其次是高血壓佔33.0%，而合併有糖尿病、高血壓者佔8.7%。收案個案有90%以上皆能按時定期就醫，且半數以上會至公私立醫院診所就醫，但至衛生所者則非常少。根據前後測個案管理記錄統計分析得知，中老年病個案對無論自身的疾病認知、飲食控制及血壓／血糖之控制，在疾病個案管理後皆顯著優於管理前。但是糖尿病個案則需加強藥物按時按量服用及藥物注射方法、注射時間、注射部位之認知與行為，對低血糖症狀的預防措施及足部護理方法之衛教。而高血壓個案較無法做到按時/按量服藥、洗澡時水溫適中、每月量血壓及適當運動，尤其是運動方面。
衛生所中老年疾病防治作業之個案來源依序是：老人健檢(94.7%)，地段篩檢(88.0%)及成人健檢(48.0%)。除了衛生所規定的條件外，個案選取標準為容易聯絡的到(85.5%)或容易有效者(63.2%)。護理人員在訪視時常遇到的問題是：效益太差(69.3%)，時間、精力耗費太多(61.3%)，無法提供普遍服務(46.7%)。無聯絡電話(22.8%)、個案不住在戶籍地址(15.2%)、街道地址更新，但戶政資料未及時更改(6.3%)是當前使用戶籍資料的困難。本研究聯結健保資料及衛生行政人力，不但讓慢性病管理之案源更加容易，工作目標更清楚，在慢病預防保健知識、行為上被保險人亦有長足進步，有助於節制被保險人之醫療資源利用。

關鍵字

衛生所 ； 全民健康保險 ； 慢性病疾病管理模式

並列摘要

Among all levers of medical service providers under the jurisdiction of Kao-Ping Branch of BNHI during 1997, we selected the diabetes and hypertension outpatients of frequent user of health care resources to home visits as a intervention study. These community follow up studies were conducted by 79 trained public health nurses of 11 health stations in Kaohsiung.
In this study, 321 clients were sufficiently complete for use. Structured questionnaires were designed as to cover the personal data and knowledge and behavior towards HBP & DM of the selected clients. Public health nurses completed the questionnaires before and after they made their home visits to the individuals in the catchments area. Data analysis was done by PC with SPSS program package.
The result of this study found that:
321 study subjects showed that 58.3% were DM cases, 33.0% were HBP cases and 8.7% were combined HBP & DM diseases. Almost 80% of study subjects could go to hospital regularly. With data collected before and after the implementation of the research in March 1999 within 4 months follow-up, 321 high-frequency health insurance of the diabetes and hypertension outpatients those disease knowledge, diet control and glycemic control, blood pressure were better than before.
It is concluded that the present scheme of Community screening program for diabetes and hypertension in Taiwan is and expensive and inefficient public health program. To fulfill more efficient and reasonable chronic illness monitoring and management system, a strategy of administering ”Adult health registration” and preventive service of BNHI system might suggest. This model shows clearly it can improve the preventive medicine knowledge and behavior of care for diabetes mellitus and hypertension outpatients, therefore, we strongly recommend the use of the referral model.

並列關鍵字

Health Station ； National Health Insurance ； Chronic disease management