腦中風病人出院準備服務銜接居家醫療整合照護模式之成效

The Essential of an Integrated Home Medical Care Model for Discharge Planning of Post-Acute Stroke Patients

10.6200/TCMJ.202003_17(1).0009

陳頌云(Sung-Yun Chen)；陳威達(Wei-Da Chen)；蔡衣帆(Yi-Fan Tsai)；侯春梅(Chun-Mei Hou)；王筱帆(Hsiao-Fan Wang)

出院準備服務 ； 居家整合照護 ； 日常生活活動 ； discharge planning ； integrated home care services ； activities of daily living

北市醫學雜誌

17卷1期（2020 / 03 / 30）

106 - 130

繁體中文

本文擬建構腦中風病人無縫式接軌的出院準備至居家整合照護模式，依個別失能程度，透過整合醫療團隊照護服務，作為日後醫院推展腦中風病人出院後隨即服務到宅，希冀能促進個案較快恢復或改善失能程度。本研究計畫目的為分析收案個案及其家屬在醫院出院準備服務滿意度及居家整合照護服務滿意度，以及追蹤個案返家後其居家跌倒發生率、日常生活活動評分、工具性日常生活活動能力評分、肌肉力量（Muscle Power）評分，以評估該模式對個案返家後的效益。計畫期間為2018年1月～2018年9月23日止，共收案30位個案。研究結果發現腦中風個案ADL量表評估由平均53.33±23.17分提升至70.83±25.63（p＜0.001）及IADL量表評估由平均6.47±5.06分提升至9.77±6.78（p＜0.001）。上肢肌肉力量由出院前平均2.94±1.11分提高至出院後平均3.6±1.26分（p＜0.000）、下肢肌肉力量由出院前平均3.53±0.78分提高至出院後平均4.17±0.69分（p＜0.000）。研究結果已有效建構腦中風病人出院後立即無縫接軌至居家整合照護，透過整合醫療團隊的照護服務，加速服務提供的正確性和適時性，確實可促進個案能較快速恢復及改善失能程度，提升返家後獨立生活能力及生活品質。

Most stroke patients are highly disabled and require long recovery period. While hospital discharge preparation services should be provided at the beginning of patient hospitalization, health professionals, patients, and family members should cooperate to integrate healthcare and social welfare resources and prepare for hospital discharge. The first week after discharge is critical for patients who receive rehabilitation as well as the caregivers. If transitional care is provided to patients to help them resolve the problems they encounter after hospital discharge, then the patients would adapt smoothly and receive adequate continued care services. In this project, we aimed to establish seamless hospital discharge preparation services and then home integrated services for the stroke patients. In this integrated medical care service, the patients are cared by the whole integrated medical team according to the severity of the disease and they are cared at home soon after discharge to look forward to a faster recovery and an improvement of the functional status. During 2018/01 to 2018/09/23, a total of 30 patients were recruited. ADL scores of the Barthel index increased from an average of 53.33±23.17 to 70.83±25.63 (p＜0.001) and the IADL scale assessment increased from an average of 6.47±5.06 to 9.77±6.78 (p＜0.001). The upper limb muscle strength increased from 2.94±1.11 to 3.6±1.26 (p＜0.000) and the lower limb muscle strength increased from 3.53±0.78 to 4.17±0.69 (p＜0.000). The results revealed that the integrated home care model effectively improved stroke patients' functional status and quality of life as well as their activities of daily living level.