臺灣六十五歲以上老年人佔總人口比超過14%,已達到世界衛生組織定義的「高齡社會」。老化伴隨著長期照顧需求,家庭照顧者常因照顧技巧不足及壓力負荷過重衍生照顧問題,長照悲歌時有所聞。2017年衛生福利部長期照顧計畫2.0(簡稱長照2.0)將被照顧者及照顧者皆納入評估機制,推動出院準備銜接長照2.0無縫接軌,在急性期住院期間藉由出院準備跨團隊服務模式連結醫療及社會資源,縮短服務等待空窗期,讓被照顧者及照顧者獲得適切的照顧援助。此為一位因跌倒活動力降低、失能臥床後壓傷發生而住院的71歲男性,出院準備服務護理師藉由跨專業團隊合作,將個案全人、全家、全程照顧需求皆納入出院準備計畫,以個案需求及照顧者角度提供衛教指導、個別化的示範教學及回覆示教等強化照顧技巧,並依據個案進食狀態及營養需求,規劃飲食提供營養衛教,使個案攝取充足的熱量,出院時立即轉銜長期照顧機構喘息,喘息結束後再連結照顧及專業服務,促使個案壓傷癒合。此個案報告提供臨床照顧者如何整合政府與社會資源,運用跨團隊合作連接長期照顧服務,協助取得社會福利資源,提供更多的支持及喘息空間,並藉由提升照顧者健康識能,提供個案整體照顧時,也促進照顧者自我管理意識,兼顧個案及照顧者身心狀態和生活品質,長期照顧的價值與意義才能得到最好的呈現。
Taiwan has become a super-aged country with more than 14% of elderly aged more than 65 years-old. This has made long term care a challenge for health care system. Traditionally, Taiwanese woman were entrusted to be the major caregiver. They often lack care skill training and directly face the stress of care alone. These factors will lead to some tragedies in long term care. The Ministry of Health and Welfare's long term care 2.0 (LTC 2.0) program incorporates the assessment system of caregiver burden and integrates the discharge planning into medical and social resources, using the interdisciplinary service model to shorten the waiting time to provide a more appropriate care service. This was a 71-year-old male, bedridden after fall with a pressure sore. Discharge prepare nursing specialist was the only window who integrated the multiple discipline team to provide the holistic care in the whole process. We provided individualized care demonstration and recheck to enhance his skill and offered health education to improve his literacy from the view of a female caregiver. We also provided individual care plan and nutritional consultation for adequate energy intake, wound care, and also the discharge plan to bridge the long term care. This case report demonstrates the route to integrate the government and social resources by using the cross team cooperation to make a smooth connection with long term care. Besides the engagement in the utility of social welfare and more supportive effort, we can also increase the health literacy and self-management concept of the caregiver in order to improve patients' good psychological and living quality. These efforts can present the value and meaning of long term care.
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