出院準備轉銜長期照護服務之成效

The Effectiveness of Hospital Discharge Planning in Transition to Long Term Care Programs

10.6200/TCMJ.202003_17(1).0002

鄭鈺郿(Yu-Mei Jeng)；劉雪玲(Hsueh-Ling Liu)；劉翠瑤(Tsui-Yao Liu)；陳美如(Mei-Ju Chen)；朱怡蓁(I-Chen Chu)

出院準備服務 ； 長照2.0 ； 長期照顧管理中心 ； discharge planning ； long-term 2.0 care program ； long-term care management centers

北市醫學雜誌

17卷1期（2020 / 03 / 30）

11 - 19

繁體中文

本文目的在探討某區域醫院出院準備服務轉銜新模式之成效。以2017年9月至2019年4月期間，配合衛福部銜接長照2.0出院準備友善醫院計畫，評估個案核定可使用的長照服務項目、取消申請之原因與出院後長照服務進入時間。發現長照需要等級6級以上佔57%，核定之服務項目以居家服務最多38.4%且平均服務等待時間為6.9±5.5天，其次為輔具購買申請30.5%、交通接送9.1%，最後以衛福部照顧管理資訊平台資料進行結案原因歸類高達34.3%因為無需求取消服務，可發現活動功能好轉返家後已能自理、服務內容不符合個案需求以及到宅服務時間無法配合等因素相關，建議仍需強化民眾對於長期照護服務的知曉度與接受度以及長照資源評估與個案管理系統之整合，應會有助於長照2.0計畫推動。

The purpose of this project was to investigate the effectiveness of a new model of discharge preparation and transfer in a regional hospital. We investigated the long-term care items approved, reasons of cancelation, and time of initiation of long term care services after discharge from the friendly hospital from September 2017 to April 2019. It was found that CMS level 6 or above accounted for 57% of the cases, and home services had a maximum request of 38.4% among other service items with an average service entry time of 6.9±5.5 days, followed by 30.5% for accessory purchases and 9.1% for transportation. Finally, according to the information of the Ministry of Health and Welfare Management Information Platform, no demands accounted for 34.3% of the reason of settlement and thus it could be deduced that the activity function of the cases was improved and they could selfcare, the services not meeting needs, or the services could not be delivered at the time requested. We suggest to strengthen the public awareness and acceptance of long-term care services and to integrate the assessment and case management systems. These should be helpful to the promotion of long-term 2.0 care program.

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