社區個案管理－整合照護模式的新紀元

Community case management-A new era of integrated care model

10.29494/LN.201912_20(4).0001

吳佳珊(Jia-Shan Wu)；周承珍(Cheng-Chen Chou)；劉純如(Chuen- Ru Liu)；江季蓁(Chi-Chen Chiang)；周芳妃(Fang-Fei Chou)；劉影梅(Yiing Mei Liou)

個案管理 ； 社區 ； 協調 ； 監督 ； REAIM模式 ； Case management ； community ； coordination ； monitoring ； REAIM model

領導護理

20卷4期（2019 / 12 / 01）

1 - 15

繁體中文

個案管理師是確保個案在健康照護上有良好協調的獨特專業人員，社區個案管理著重的是群體照顧，更強調修正系統制度上的不足，找出群體的能力、社會資源、而進行資源連結。目前台北市衛生局將公共衛生業務調整成健康促進和個案管理，國立陽明大學社區健康照護研究所提供碩士級的個案管理教育訓練。社區個案管理的流程分為篩檢個案、需求評估、發展計劃、執行服務、協調監督、及監測評價，其中最特別的就是協調監督。為了要影響更多的群體以及產生更大的效應，以REAIM模式說明不同層級的社區個案管理師如何在涵蓋面，有效面，參與面，執行面，維持面上達成任務。最後並以肥胖防治在社區個案管理上，中央，衛生局，衛生所，社區營造單位，以及獨立的個案管理師獨特的功能與角色。最後分享護理人員已然開業項目中，均可擴張功能，立即扮演社區個案管理師角色。診所經理、獨立護理站、護理診所則是全新之個案管理師角色。

Case managers are unique professionals who ensure that cases are well coordinated in health care system. Community case management focuses on greater population care. It also emphasizes on the modification of system deficiencies, finds the ability of the group, community resources, and connects all resources. At present, Taipei City Health Bureau adapts its public health services to health promotion and case management. The Institute of Community Health Care in National Yang -Ming University provides master-level case management education and training. The procedures of community case management are divided into screening cases, necessity assessment, development planning, execution service, coordinated supervision, monitoring, and evaluation. The most exceptional one is coordinated supervision. In order to persuade more people and create greater effects, the REAIM model is employed to account for community case managers at different levels in order to achieve mission in the area of coverage, effectiveness, participation, implementation, and maintenance. In terms of obesity prevention in the cases management of the community, as well as the central authority, the health bureau, the health center in community, the community agents, and hence defines the distinctive function and characteristic of independent case managers. Finally, we urge the nursing staffs with projects already open were able to expand their function and adapt the role of community case managers immediately. Clinic managers, independent nursing stations, and nursing clinics on the other hand are newly developed personnel to fit the role of case manager in the near future.

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