「社區安寧」整合性照護網絡建立與運作之成效

Effectiveness of the Establishment and Operation of the Integrated Care Network for Community Hospice Care

蔡旻秀(Min-Shiow Tsay) ； 張亦慧(Yi-Hui Chang) ； 王靜瑜(Ching-Yu Wang) ； 楊久嫻(Chiu-Hsien Yang) ； 劉子沄(Zi-Yun Liu) ； 李純瑩(Chun-Ying Lee) ； 陳虹錚(Hung-Cheng Chen) ； 吳建誼(Chien-Yi Wu)

《安寧療護雜誌》 25卷3期 (2021/07) Pp. 253-268

https://doi.org/10.6537/TJHPC.202107_25(3).04

摘要

根據研究顯示，能在宅善終是多數末期病人的心願，然而末期病人變化多端的病情是在宅善終的一大挑戰。現今安寧居家團隊大多是由醫院團隊組成，較無法提供可近性、即時性的安寧居家訪視；此外社區安寧居家因醫療人員投入意願低、缺乏安寧居家相關經驗，使得推動社區安寧居家療護有所困難，進而讓病人及家屬對於在宅善終缺乏信心，導致有些病人與家屬選擇於醫院度過生命終點。本文分享醫院安寧療護團隊藉由輔導社區團隊偕同訪視、定期個案討論及建構照護網絡來共同照護病人，由個案管理師擔任雙向溝通窗口，依據病人和家屬個別需求轉介社區安寧居家團隊來提供可近性、即時性安寧居家服務，協助末期病人無縫接軌回到社區，來落實安寧療護中的全社區照護，最終能有機會在宅善終。

關鍵字

安寧療護 ； 居家照護 ； 整合照護 ； 社區

並列摘要

According to previous studies, dying at home is a wish of most terminally ill patients; however, various clinical problems pose a big challenge for terminally ill patients who wish to die at home. Nowadays, most hospice home care teams are made up of hospital-based care, making it hard to afford accessibility and timely home care visits. Besides, it is challenging to promote community hospice home care due to insufficient community medical staff involvement and lack of hospice home care experiences. Therefore, terminally ill patients and their families lack the confidence to die at home, and finally, some of them chose to die in the hospital. In this article, the experienced hospital hospice care team assisted the community hospice care team in visiting terminally ill patients, arranged care discussions regularly, and constructed an integrated hospice home care network. The experienced hospital hospice care team's case manager posed a mutual connection window to help terminally ill patients and their families refer to an appropriate hospice home care team. The home care team aims to help terminally ill patients go back to the community area smoothly and receive accessibility to timely home care based on their needs. It would carry out the whole community hospice care and help patients dying at home.

並列關鍵字

hospice care ； home care ； integrated care ； community

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