建置在地型社區安寧照護網絡

Network Development of a Localized Community-Based Palliative Home Care Service

10.6537/TJHPC.202103_25(2).01

劉美玲(Mei-Ling Liu)；陳鼎達(Ting-Tat Chan)；謝依靜(I-Ching Hsieh)；林妙穎(Miao-Ying Lin)；郭雅慧(Ya-Hui Kuo)；陳淑貞(Shu-Jen Chen)

社區安寧 ； 安寧居家 ； 死亡地點 ； 跨理論模型 ； community hospice care ； hospice home care ； place of death ； transtheorectical model

安寧療護雜誌

25卷2期（2021 / 03 / 01）

97 - 109

繁體中文

背景：為了讓更多人能達成在宅在地善終的願望，台灣於2014年開始推動社區安寧服務並納入健保給付項目，但因社區提供安寧服務的量能不足，以致接受社區安寧照護的病人未如預期增加。目的：藉由在地型社區安寧照護網絡的建置，提升社區安寧服務的量能。方法：政策方面，成立社區安寧推動小組、建置「嘉義地區社區安寧照護網絡」（簡稱嘉安網）、建構轉介個案管理流程與資訊平台、品質檢測等；教育方面，按照社區單位準備度提供個別性指導計畫、辦理社區安寧訓練課程、實地訪視輔導、進階繼續教育、共融營、研討會及個案討論會等；宣導方面，舉辦在地基層醫療單位的宣導會及社區民眾安寧理念宣導等，積極推動在地安寧照護。結果：藉由嘉安網建構，共有35個社區醫療院所加入服務，服務末期病人超過450位，轉介來源有醫院、長照機構、居家醫療團隊、診所、民眾、長照管理中心等。收案378位病人，平均年齡82歲，52.9％癌症末期，31.7％末期腦病變。結案336人中，平均收案74天，結案原因以死亡最多（81.5％）。此外，有80.3％的病人未再入院，81.3％在經常居住所在地死亡。推動期間，區域醫院甲類安寧居家服務之病人量不降反升。結論：透過在地化社區安寧網絡建置，培育社區醫療院所末期照護能力，並作為後援資源，提升社區安寧照護的量能，並使更多社區末期病人得到較高品質的善終照護，達成「在地善終」的願望。

Background: At the end of life, most people desire to have a good death in place. Home is the preferred place of a death for most patients, yet over half of them die in hospitals. To accomplish the desire of a good death in place, community-based palliative home care service has been initiated and covered by health insurance in 2014 in Taiwan. However, the number of patients receiving palliative home care did not increase as expected because of insufficient capacity of providers in the community. Purpose: To enhance the capacity of palliative home care provided by community professional caregivers through development of a local network. Methods: A community-based palliative home care network was developed by a regional hospital in southern Taiwan. Implementation strategies included: community resources survey, health care workers recruitment, readiness assessment, individualized instructions and training programs, case management and resource coordination, team support, and development of an information platform. Results: During the organization of a local palliative home care network, 35 medical institutions were recruited, including 16 public health centers, 9 community clinics, 6 home care agencies and 4 district hospitals. A total of 450 patients were referred by hospital palliative care team, long-term care facilities, hospital outpatient clinics, home care agencies, etc. As of the end of 2019, 378 patients with an average age of 82 were enrolled into the community palliative home care program. More than half (52.9%) were diagnosed with cancer, while 31.7% with end-stage brain diseases. The number of case closure was 336. The major reason of case closure was death (81.5%), followed by referral to hospital-based palliative home care (6.3%), referral to outpatient clinic (6.8%) and general home care (5.7%). Among these 336 cases, 80.3% were never readmitted and 81.3% died in their usual place of residence. During this period, the patient volume serviced by the supporting hospital palliative home care team increased steadily. Conclusions: The capacity of palliative home care provided by community practitioners could be enhanced by local network development. More end-of-life patients in the community will benefit from high quality palliative care and accomplish their wishes of dying in place.

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