居家醫療整合照護中營養師的角色

The Role of Dietitians in Integrated Home Medical Care

10.6200/TCMJ.2017.14.3.04

林宜芬(Yi-Fen Lin)；陳珮蓉(Pey-Rong Chen)；饒月娟(Yueh-Chuan Jao)；李光申(Oscar K. Lee)；翁林仲(Lin-Chung Woung)；黃勝堅(Sheng-Jean Huang)

居家醫療整合照護 ； 營養診斷 ； 營養介入 ； 營養師 ； 居家營養師 ； Integrated Home Medical Care ； Nutrition Diagnosis ； Nutrition Intervention ； Dietitian ； Homecare Dietitian

北市醫學雜誌

14卷3期（2017 / 09 / 30）

295 - 304

繁體中文

臺灣已經邁入高齡社會，老人醫療照護從長期照護、家庭醫師責任制到居家整合醫療計畫，顯示公共衛生政策逐漸走向整合，且更貼近病人需求的照護模式。然而，營養照護需求與營養師角色與任務，仍處於模糊與缺乏共識的階段。為能落實全人醫療，強化居家醫療團隊的服務品質，臺北市立聯合醫院營養師於104年參與家庭醫師責任制的居家與安寧的營養服務，並於105年3月1日居家整合醫療計畫開始即加入醫療團隊服務，至105年7月已完成107位居家營養照護服務，其中包括居家醫療、重度居家醫療及安寧療護等個案。經由營養師訪視紀錄之回饋，營養診斷主要有：食物與營養知識不足、營養不良、營養素攝取不均衡、製備食物或餐點的能力不足、獲取營養物質供應的管道受限、吞嚥困難、經口攝取不足及咀嚼困難等。營養師介入項目，包括飲食內容調整、管灌飲食指導、慢性病飲食指導及飲食質地調整製作指導等。由此先期第一階段的營養訪視經驗顯示，居家整合醫療個案存在需積極介入的營養問題與需求，建議在收案評估與醫療計畫應涵蓋營養照護部分，並且應有合理的營養相關支付項目以利計畫之持續推動，進而提升照護品質及降低照顧者的壓力。因應高齡社會發展的需要，營養師服務從醫院臨床營養、社區營養，延伸至居家營養，甚至安寧緩和營養，居家營養師是深具發展潛力的新專科，營養師須加強相關專業以提升照護的能力。

Integrated Medical Homecare is a care model that approximates patient's need better. However, demands for nutrition care of the model remain unclear. The dietitians of the Taipei City Hospital started joining the Medical Homecare team and has provided nutrition care since March 2016 and 107 cases had been cared for nutrition on July 2017. The major nutrition diagnoses of the patients included food and nutrition related knowledge deficit, malnutrition, imbalance of nutrients, impaired ability to prepare foods and meals, limited access to nutrition-related supplies, swallowing difficulty and others. The dietary interventions included dietary modifications to improve nutrients intake, instruction of tube feeding, chronic disease related nutrition education, adjusting food texture and others. To our experiences, aggressive nutritional intervention is imperative for these patients in the prevention of malnutrition and complications related to chronic diseases. We recommend to include nutrition consultation in the payment scheme of national health insurance for the integrated medical home care to improve the quality of medical care and reduce burden of caregivers. Moreover, beyond medical nutrition therapy and community nutrition services, dietitian services have been extended to include home and palliative care. Home care dietitian is an emerging sub-specialty with potential for further development, and dietitians should reinforce their professional skills to elevate their care ability.