提升病人出院準備銜接長照2.0之轉銜率

Improving the Transition Rate of Patient Discharge Preparation with Connection to Long-Term Care 2.0

10.6692/KJN.202104_38(1).0003

周香吟(Hsiang-Yin Chou)；鄭雅文(Ya-Wen Cheng)；戴文芳(Wen-Fang Tai)；李榮真(Jung-Chen Lee)

長照2.0 ； 長期照護 ； 轉銜率 ； Long-term Care 2.0 ； long term care ； transfer rate

高雄護理雜誌

38卷1期（2021 / 04 / 01）

22 - 33

繁體中文

由於台灣人口結構急速老化，2018年65歲以上老人占14.50%，在過去政府推動長照十年期間，出院銜接居家照護耗時且不便民，導致家屬返家照顧意願薄弱；統計2018年1～3月本院復健科病房長照2.0平均轉銜率僅10.9%，故引發本專案小組動機；分析本院復健科病房轉銜率偏低原因有（一）無收案標準流程，未有收案初篩表；（二）醫護人員未接受長照2.0課程；（三）醫院未有長照2.0宣導。本專案執行期間自2018年9月至11月，改善方案有（一）設計長照2.0初篩表，訂定標準收案流程；（二）安排醫護人員長照2.0在職教育；（三）提供長照2.0衛教單張及製作長照2.0宣導影片。經改善方案後，9～11月平均轉銜率提升至51.3%，增加家屬返家照顧意願，讓出院照顧無縫接軌長照2.0服務，提升長期照顧者與被照顧者之生活品質。

The population is aging fast in Taiwan. In 2018, 14.5% of the population was over 65 years of age. The government has promoted the ＂10-Year Long-Term Care＂ program during the past decade; however due to the time-consuming and inconvenient process of the transition from discharge to home care, family members are less willing to prepare for home care. First-quarter statistics of 2018 indicate that the average transition rate for Long-Team Care 2.0 was only 10.9% in the rehabilitation ward, which motivated our project team to improve the transition rate. Reasons for the low transition rate include: (1) lack of standard protocol and screening table for case enrollment; (2) no education training on Long-Term Care 2.0 for the medical staff; and (3) lack of announcement of the Long-Term Care 2.0 in the hospital. During the implementation of the project from September to November in 2018, the approaches for improvement included: (1) designing a Long-Term Care 2.0 screening table and setting the standard protocol for case enrollment; (2) holding education training classes concerning Long-Term Care 2.0 for the medical staff; and (3) providing Long-Term Care 2.0 health education sheets and producing a video for announcement on Long-Term Care 2.0. After the implementation of these approaches for improvement, the average transition rate for Long-Term Care 2.0 from September to November increased to 51.3%, and family members were more willing to prepare for home care after discharge, allowing discharge home care to be seamlessly integrated into Long-Term Care 2.0 and thereby improving quality of life of caregivers and patients.