跳脫框架的居家醫療：失能長者多重專業照護

Multidisciplinary Home Care for the Elderly

10.6200/TCMJ.201910/SP_16.0007

莊美幸(Mei-Hsing Chuang)；洪若樸(Raw-Pou Hung)；鍾慧(Huei Chung)；莊惠文(Hui-Wen, Chuang)；郭妍伶(Yen-Ling Kuo)；楊曉綾(Hsiao-Ling Yang)；陳香岑(Siang-Cen Chen)；許毓芬(Yu-Fen Hsu):李志清(Chih-Ching Lee)；許良豪(Liang-Hao Hsu)；洪嘉蔚(Chia-Wei Hung)；官玫秀(Mei-Hsiouh Guan)；林素妃(Suh-Fei Lin)

居家醫療 ； 跨領域團隊合作 ； 多重用藥 ； 健康識能 ； 吞嚥功能訓練 ； home medical care ； transdisciplinary collaboration ； polypharmacy ； health literacy ； swallowing training

北市醫學雜誌

16卷附冊（2019 / 10 / 31）

68 - 74

繁體中文

臺北市立聯合醫院提供居家醫療整合照護服務，讓跨團隊專業人員進入居家，參與的人員有醫師、護理人員、藥師、營養師、物理治療師、語言治療師、社工師、法師或牧師及志工，提供整合醫療和高品質的生命末期照護，期使老年人在家裡也能夠得到妥善的醫療照顧。本文提出照護的經驗中，各成員之實際作為及病患獲得之幫助，做為未來提供跨團隊居家醫療的參考。

The Taipei City Hospital provides a well-integrated home-based and high quality medical care for the end-of-life. The health provider team includes physicians, nurses, pharmacists, dietitians, physical therapists, speech therapists, social workers, Buddhist monks or priests, and volunteers. The purpose is to let the elderly receive good health care at home in their remaining years. We describe the actual actions of the team members and the helps obtained by the patients for future reference of transdisciplinary collaboration.