衰弱高齡者急性後期居家整合照護服務

Home-Based Integrated Post-Acute Care for Frail Elderly

10.6200/TCMJ.201910/SP_16.0004

李旻璋(Min-Chang Lee)；吳岱穎(Tai-Yin Wu)；陳一萱(I-Xuan Chen)；陳明正(Ming-Chen Chen)；林怡君(Yi-Chun Lin)；蕭勝煌(Sheng-Huang Hsiao)；翁林仲(Lin-Chung Woung)

衰弱 ； 高齡 ； 急性後期 ； 老年周全性評估 ； 居家物理治療 ； 整合照護 ； frailty ； old age ； post-acute care ； comprehensive geriatric assessment ； home-based physical therapy ； integrated care

北市醫學雜誌

16卷附冊（2019 / 10 / 31）

38 - 46

繁體中文

罹患衰弱症的高齡長者，遭遇輕微的外在壓力即可能產生失能，增加醫療照護需求。歐美國家在30年前即發展出不同模式的急性後期整合照護，其重要性不言可喻。本文分享臺北市立聯合醫院仁愛院區的衰弱症居家急性後期照護服務經驗。完善的衰弱高齡急性後期整合照護仰賴於：出院前的老年周全性評估與介入、返家後的居家物理治療照護服務，與服務完成後安排轉銜居家醫療和長期照護服務。如何找出適合的病人族群，促使主治醫師參與，及讓病人瞭解服務之重要性，是我們今後努力的方向。

Frail elderly would become disabled and increase the needs for medical care even after a minor stress. The European countries and the US have already developed different integrated post-acute care (PAC) models thirty years ago. Its importance is beyond words. We share our experiences of frailty home PAC in the Renai Branch, Taipei City Hospital in this article. An ideal frailty PAC relies on comprehensive geriatric assessment and intervention before discharging from the hospital, home-based physical therapy when return home, and arranging the transition to home-based medical care and long-term care after service. Our next step will be to find proper patient population, get physicians to involve, and let patients understand the importance of PAC.