長期照顧十年計畫服務輸送之檢視—以照顧管理專員觀點為例

View of the service delivery of the ten-year long-term care program: From a Care manager's Perspective

黃于殷(Yu-Yin Huang)

指導教授 ： 鄭清霞

國立中正大學/社會科學院/社會福利學系/碩士(2013年)

摘要

在快速老化的人口危機與家庭功能消退的趨勢下，長期照顧需求已不容小覷，有鑑於此，行政院遂於2007年正式頒定長期照顧十年計畫作為至今執行長期照顧服務的重要依據。本研究主要在於了解該計畫目前的執行狀況，並試圖從「需求評估」、「給付內涵」及「服務輸送」等三方面來深入探究整個服務設計存在的困境與議題，並檢視執行者所處勞動條件存在哪些不利因素，以作為日後政策修訂上的參考。

本研究以周旋於使用者與服務提供者之間的基層執行者-照顧管理專員作為主要研究對象，並以立意及滾雪球等取樣方式立基，選取出中南部15位照顧管理專員進行深度訪談。

研究結果發現在需求評估方面，照顧需求的共識過程隨著家庭互動型態的不同產生整合上的差異，又目前所採用的評估工具無論是內容周延度與操作型定義的認定上仍顯不足與缺乏實務共識，甚至失能認定標準所選用的評估指標及計分方式有排除或低估非肢體障礙者之使用機會與需求的現象；在給付內涵方面，給付與否與給付程度會受到「個人需求」、「家庭優勢」、「國家角色定位」以及「資源充足面」之影響。在給付種類上則缺乏對夜間照顧需求者的對應服務、到宅團隊缺乏多元專業的組合(如藥師、營養師、牙醫師等)、知性與靈性的深耕服務不足，甚且缺乏團體概念的服務設計。在給付額度的設計中也因需求者所處的特殊狀況、缺乏與健保制度相調合以及政策目標與需求期待落差等不同的審視標準而產生不足之感受，另外，因與健保制度間缺乏調和以及服務項目之間缺乏對費用的區隔性，也相對影響使用者對於費用的接受度。

在服務輸送過程方面，資源的不足相對影響了需求導向及案主參與與自決原則的落實，也造成服務可近性障礙，影響服務媒合結果，再者，受訪者內部所建立的運作與管理機制對案主權益維護與責信的因應方式造成ㄧ定程度的影響，同時也產生不同程度的合作困境。在整個服務輸送過程中不難發現照顧管理者是整個服務推送過程的關鍵角色，其所在的勞動處境更牽動著服務輸送運作品質，本研究也因此發現照顧管理者目前被賦予的工作職責與福利仍有待釐清與加強，工作環境的支持系統也有賴更進ㄧ步地建構。

由於評估工具的適切性與支給付設計的細緻化均有助於控制長期照護經費支出，對於未來長期照護保險實施具有重大意義，本文因此提出以下建議:一、評估工具的再檢視與評估操作的再定義；二、國家照顧份際的再討論以及支給/付設計的再衡量；三、長期照顧推動小組及偏遠地區基層衛生單位照顧功能的擴增；四、照顧管理專員勞動條件的再規劃，並建議建構出相關福利體系縱橫向連結機制。

關鍵字

長期照顧 ； 服務輸送 ； 需求評估 ； 服務給付 ； 照顧管理專員

並列摘要

In the trend of rapid population aging crisis and worse family function, the need for long-term care should not be underestimated. In view of this, the Executive Yuan in 2007 formally promulgated the ten-year plan for long-term care as an important basis since the implementation of the long-term care services. This study aimed to understand the current implementation status of the plan and explore the extant plight and issues of the entire service design from “needs assessment,” benefit content” and "service delivery” aspects. It also examined what adverse factor an executor in labor conditions has and then serves as reference on policy adjustments in the future.

Care managers, between the service receivers and the service provider in service implement grassroots, are the main research object in this study.On a basis of purposive and snowball sampling Lark, I selected 15 care managers in the central and the southern regions of Taiwan and conducted in-depth interviews.

In the needs assessment, the present findings is that care needs’ consensus will result in different degrees of integration due to different patterns of family interaction.
And assessment tools use is still insufficient and lack of practice consensus in the content integrity and the operational definition.Besides, the disability standards identified by the assessment and scoring indicators have a phenomenon which exclude or underestimate the opportunity to use and the demand of the non-physical disabilities. In the benefits content,how mcuh benefit is given will be subject to “individual needs”, "home advantage", "national responsibility"and“ resource adequacy " level. In the type of benefit, it is lack of corresponding services of people that have care needs at night, the lack of diverse professional house team, the lack of intellectual and spiritual service, and the lack of a service group concept design. In the amount of benefits, service users engender the feelings of inadequacies in special circumstances.

In the service delivery process, the lack of resources relatively impacts the implementation of demand-oriented and the principle of self-determination. It also causes barriers to service accessibility. Furthermore, the operation and management mechanisms established by long-term care management centers will influence the extent of client interest in maintaining and accountability. It will produce different degrees of cooperation plight as well. In addition, the study also finds that it still needs much to be desired for care managers to know their obligation and have a better workplace environment and welfare.

Appropriate assessment tools and refinement of the payment and benefits design are to help control the long-term care expenditures. It is significant for the future implementation of long-term care insurance. Therefore, this paper proposes the following: Firstly, assessment tools are re-examined and operation is redefined. Secondly, the state caring role is re-discussed. And payment and benefits design is re-assessed. Thirdly, long-term care promoting group and the care function of the basic health units in faraway areas are expanded. Finally, care managers in working conditions are re-planned. And the relevant welfare system needs to be constructed to form a longitudinal and transverse link mechanism.

並列關鍵字

long-term care ； service deliver ； need assessment ； service benefits ； care manager

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