人口老化下的居家醫療照護整合網絡—以嘉義地區為例

Abstract

目標：探討醫院與社區建構「居家醫療照護整合網絡」的運作模式、影響因素、參與者互動，並提出應對超高齡社會的建議。方法：本研究為質性研究，對嘉義Ａ醫院與社區建構的一組居家醫療照護整合網絡，進行滾雪球式取樣與半結構式深度訪談，最後歸納整理並輔以文獻分析。結果：研究呈現受訪網絡、參與者介紹與參與動機、個案管理、資訊討論平台，並陳述失能者在宅照護的需求、醫藥到宅的困難、醫療與長照協作的具體方式。計畫實行影響了受訪網絡承載能力與醫療照護產業。結論：醫院可發展敘事醫學、經營外展服務模式、拓展「醫療長照複合聯盟」。醫療與長照成員（含東南亞籍看護工）要相互瞭解。建議提高參與者所得、整合此計畫的「個案管理」與長照「照管專員」並增加人力、排除社區安寧限制。如何協助長者持續自主尊嚴地生活，從好好老去、到好好離去，健全醫療與長照的整合網絡，是公共衛生可思考的方向。

Purpose: The aim of this study was to explore influence factors of the integrated home health care network, the relationship of the participants, and the strategies for hyper-aged society. Methods: This study uses qualitative, snow-ball-sampled, and in-depth, semi-structured interviews for data collection. Participants from the team of the hospital and the community in the Greater Chiayi Area, enrolled in the “integrated home medical care program” by the National Health Insurance Administration in Taiwan, were invited. Data analysis was conducted by categorized interview data and variously emerged themes. Results: This study introduced the service delivery process, participants, tools of “Information and Communication Technology”, and case management. Some difficulties occurred when caring the disabled at home. It was not easy to deliver home health care. Collaboration between medicine and home care was advantageous. The program affected the power of the interviewed network. Conclusion: Hospitals can develop Narrative Medicine, 'home-centered' outreach care model, and 'Medical-long-term Care Alliance'. People trained from medicine or long-term care （including the Southeast Asian care workers） should know each other well. The income of participants should be elevated. The authority should combine “case managers of home health care” and “care managers from long-term care” with more manpower. The obstacles of community hospice for the primary care teams should be solved. The impact of hyper-aged society is preventable, and it’s important for public health to help the old to live with autonomy and respect.