社區式照顧管理模式的設立與初步評價

Establishment and Preliminary Evaluation of a Community-Based Care Management Model

10.6288/TJPH2004-23-03-04

戴玉慈(Yu-Tzu Dai)；張媚(Mei Chang)；呂寶靜(Pau-Ching Lu)；吳淑瓊(Shwu-Chong Wu)

社區式長期照護 ； 照顧管理 ； 跨專業 ； 照顧經理 ； community-based long-term care ； care management ； interdisciplinary ； care manager

台灣公共衛生雜誌

23卷3期（2004 / 06 / 01）

197 - 208

繁體中文

目標：本行動研究目的在現劃與執行社區式長期照護的管理模式，並進行初步評價。方法：以協助民眾在地老化為宗旨，以跨專業團隊建立長期照護各專業分工模式，訓練照顧經理對失能者提供綜合評估、擬定照顧計畫、整合資源、協調服務、監測服務結果。在嘉義市與三峽鶯歌地區分設兩個實驗社區中心，由照顧經理擔任長期照護需求者和照顧體系間的橋樑，聯結服務。以建議服務與實際服務提供為指標評價管理的執行狀況；並利用兩個實驗社區中心各7次個案討論會的紀錄進行內容分析，探討照顧經理的訓練是否與其角色相符。結果：照顧管理服務和業務監控流程已建置完成，照顧經理共建議1511個服務，民眾只接受482 個，服務接受度31.9 %，跨專業照顧諮詢小組對照顧經理提供的指導以評估和服務協調或連結最多。結論：國內首項結合社政與衛政資源的社區式長期照護個案管理模式在實驗社區內已初步建立，民眾的接受度在學理和政策之意涵有待深入探討。

Objectives: The purpose of this action research was to design, implement, and evaluate preliminary outcomes of a community-based care management model for long-term care. Methods: Chia-Yi City and San-Shia /Ing-Ger area of Taipei county were selected as a samples of the urban and rural community respectively, Care managers were recruited and trained while the experimental community centers were established in these two communities. The first outcome indicator was the number of suggested services and the number of actual services that care managers linked indicating implementation of care management. The second indicator was the major topics discussed in interdisciplinary case conferences indicating the extent of congruence between the focus of training and the expected role of care managers. Results: The services of care management were successfully delivered. A total of 1511 community - based services were suggested to the potential users by the care managers with only 482 service suggestions being accepted. The service utilization rate was 31.9 %. The 2 most discussed topics during case conferences were the assessment and coordination, and the linkage of services that were consistent with the role of care managers. Conclusions: For this action research, a care management model that integrated health and social services was established. The low acceptance of community-based services needs to be further explored.

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