某醫學中心試辦出院準備銜接長照2.0計畫成效初探

Outcome of Discharge Planning Linked to Long Term Care 2.0 Project in a Medical Center

10.6320/FJM.201809_22(5).0002

詹惠雅(Hui-Ya Chan)；黃獻樑(Hsien-Liang Huang)；游芝亭(Chih-Ting Yu)；丁施丹(Shih-Tan Ting)；闕圻安(Chi-An Chueh)；徐于絜(Yu-Chieh Hsu)；林瑛釗(Ying-Chao Lin)；曾家琳(Chia-Lin Tseng)；蔡兆勳(Jaw-Shiun Tsai)；余忠仁(Chong-Jen Yu)

出院準備 ； 長期照顧 ； 照顧管理專員 ； 照管中心 ； discharge planning ； long-term care ； case manager ； long-term care management center (LTCMC)

台灣醫學

22卷5期（2018 / 09 / 25）

474 - 481

繁體中文

本研究目的在探討某醫學中心試辦出院準備銜接長照2.0計劃之成效。以橫斷面研究法，調査2017年6月至9月試辦與非試辦單位轉介照管中心個案數、與轉介率，收集與分析轉介個案之基本資料、轉介單與照管中心回覆單，以及個管師之記錄，發現試辦病房轉介51人，轉介率為5.23％，非試辦單位轉介41人，轉介率為0.1％，兩者呈現顯著差異。申請長照服務，以居家服務最多（58.8％），其次輔具購買租借（54.9％）、喘息服務（51.0％）與交通接送（49.0％）；但通過核定項目以喘息服務（65.0％）最多，其次交通接送（55.0％）、居家服務（50.0％）與輔具租借購買（40.0％）。出院後取消申請服務達31人，主因服務需求、資格和服務期待不符（38.7％）。以受訓合格專人協助銜接長照2.0計劃，確能提升轉介率，建議運用資訊系統估算合乎收案條件者，並參考個案管理時間來估算人力；同時，簡化評估量表，授予醫院核定部分服務項目，應有助於出院準備銜接長照2.0計畫之推動。

The purpose of this study was to investigate the outcome of discharge planning linked to Long Term Care 2.0 project. From June to September 2017, we compared the transfer amount and rate between wards with and without specialized case manager (SCM). Patients' basic data, transferring sheet, and feedback sheet from long term care management center (LTCMC) collected. In addition, the case managers' records also included as study materials. There were 51 patients referred to the LTCMC of SCM wards, and the referring rate was 5.23%. The outcome was significantly higher than the other wards (41 patients, 0.1%). The applied services included care services (58.8%), assistive device purchases or rental (54.9%), respite care services (51.0%), and transportation services (49.0%). However, the LTCMC certified finally were mainly respite care (65.0%), transportation care services (55.0%), care services (50.0%), and assistive device purchases or rental (40.0%). The factor ranked first among the patients not receiving the services was financial factor and services linkage availability (38.7%). Having a specialized case manager did provide more referred patients and referred rates on discharge planning linked to long term care 2.0 project. We suggested the requirement of manpower could estimate the numbers of patients who fit the service criteria by informatics system and consider the consuming time of case management process. Meanwhile, simplify the evaluation scale and authorizing the hospital SCM to approve some service items would be helpful for the project.

1. 尹銘芳(Ming-Fang Yin);丁施丹(Shih-Tan Ting);謝佳穎(Chia-Ying Hsieh);詹惠雅(Hui-Ya Chan);潘信良(Shin-Liang Pan);林瑛釗(Ying-Chao Lin);林綉珠(Shou-Ju Lin);劉秀雲(Hsiu-Yun Liu)(2022)。提升病人轉銜長照2.0成效之計畫。台灣醫學。26(2)。210-219。