運用高效能照護模式提升長照個管師的整合照護服務

Improving Integrated Care of Long-Term Care Case Managers by Applying High-Performance Healthcare Model

10.6200/TCMJ.201910/SP_16.0008

吳麗蘭(Li-Lan Wu)；黃美齡(Mei-Ling Huang)；董恩璇(En-Hsuan Tung)；楊婉君(Wan-Chun Yang)；林雅真(Ya-Chen Lin)；俞克弘(Ker-Huang Yu)；張庭卉(Ting-Hui Jhang)；胡慧蘭(Sophia Huey-Lan Hu)

高效能照護模式 ； 長照個管師 ； 整合照顧 ； high-performing community care model ； long-term case manager ； continuum care

北市醫學雜誌

16卷附冊（2019 / 10 / 31）

75 - 82

繁體中文

臺北市政府因應推動長照2.0計畫，首推都會型持續社區整合照顧模式，透過佈建綿密的長照服務資源，提供醫養結合之整合照顧創新模式，強調在地、即時、無縫接軌的連續社區照顧。長照個管師是社區整合照顧服務中的靈魂人物；北市聯醫醫養結合照顧服務發展一年多，因長照個管師背景及經驗不一，且缺乏照顧教育訓練即投身服務，致遇到專業服務的瓶頸及服務過程常面對家屬個案的質疑，加上無系統化的服務流程，讓長照個管師感到挫折無助。本文以社區長者需求為目的，運用高效能照護模式為架構，導入相關改善策略及資源，給予長照個管師教育訓練、實務指導及標準作業指引，讓其角色得以發揮，進而提升其服務品質及信心，做好長照整合的照顧服務。

There is a need to develop integrated care in respond to the 10-year long-term care program in Taiwan. We have integrated the healthcare and community services in order to provide a local, real-time, seamless continued community care. Long-term care case managers play a vital role in integrating resources in the community. However, their performances vary according to their clinical background and experiences. In addition, because of a lack of care experience and an immediate need to provide services, it is easy to come to a bottleneck and be questioned by the patient’s family during services. Further, the absence of a systemic operation flow often frustrates the managers. Based on the needs of elderly in community, this article introduces the improvement strategies and resources, education trainings, practical supervision, and development of standard operating guidelines by using the high-performance healthcare model. As the result, the long-term care case managers can play their roles, improve their performance and confidence, and conduct the long-term integrated care service on tract.