從醫院到社區的全人照護－建構完善的出院準備服務

Holistic Care from Hospital to Community-Building a Comprehensive Discharge Planning Service

10.6200/TCMJ.201910/SP_16.0002

吳孟嬪(Meng-Ping Wu)；馮容莊(Rung-Chuang Feng)；施至遠(Chih-Yuan Shih)；徐愫萱(Su-Hsuan Hsu)；鄒淑萍(Shu-Ping Chou)；朱怡蓁(I-Chen Chu)；黃勝堅(Sheng-Jean Huang)

出院準備服務 ； 社區資源 ； 轉銜服務 ； 跨專業團隊 ； discharge planning ； community resource ； transition care ； interdisciplinary team

北市醫學雜誌

16卷附冊（2019 / 10 / 31）

10 - 24

繁體中文

北市聯醫以建構亞洲第一個『無縫接軌的出院準備服務機構』為目標，運用4P理念提供病人一條龍的服務，為能讓其出院後安心居家生活，更發揮跨專業團隊的整合照護機制，為能讓病人及家屬共同參與決策，依照病人需求，提供醫病溝通會議、出院準備跨團隊會議及出備會議等三階段的會議模式，為病人後續照護而準備，及早規劃銜接社區資源，含括了健康促進、社區復健、輔具服務、喘息服務、居家醫療、居家護理及安寧居家或安寧病房等照護資源，朝向預防病人或家屬受苦（Prevention）、預見問題有效的規劃資源轉介（Predictive）、重視病人個別需求（Personalized）以及跨團隊、病人、家屬、銜接團隊共同參與（Participatory）之目標而努力。讓家屬放心，病人也能安心回歸社區，以提升病人生活品質，也減少病人反覆住院及或重返急診等問題，藉此減少醫療資源之耗用，共創多贏局面。

Taipei City Hospital(TCH) aims to form the first ＂Seamless discharge care organization＂ in Asia, with the application of the idea of 4P, TCH provide the patients with the all-in-one service package for the patients to live securely after discharge. In order for the patients and families to participate in the shared decision-making, TCH provide them with three-stages meeting model, including physician-patient meeting, interdisciplinary team meeting, and discharge preparation meeting according to the patients' needs. In order to prepare for the patient’s follow-up care, TCH also plan for the connecting community resources, including health promotion, community rehabilitation, assistive device service, respite care service, home-based medical treatment, home-based nursing, home-based palliative, or palliative wards, and other caring resources. These are to achieve the goal of pain-suffering prevention (Prevention), foresee problems and effective planning for resource referral (Predictive), respect each patient's needs (Personalized), andinterdisciplinaryteam, patients, family, and bridging team's participation (Participatory). By doing so, the families can rest assured, the patients may reintegrate into the community, the patient’s living quality can be improved, and the problem of readmission and returning back to the emergency room can be reduced. Therefore, the medical resources waste can be diminished, and so the greatest benefit can be created altogether.