居家醫療照護在偏遠地區的實施-以東部某地區醫院為例

Abstract

研究目的： 瞭解於偏鄉會影響照護服務團隊、病患及家屬參與「全民健康保險居家醫療照護整合計畫」意願的因素，計畫執行的問題，支付金額或給付範圍是否符合期待，及尚未加入服務的醫事人員對參與計畫意願或影響因素探討，並對個案機構未來如何擴大服務量能或讓更多醫事人員加入居家醫療服務進行策略研擬與評估。 研究方法： 本研究蒐集美國、日本、法國、澳洲居家醫療照護服務推行與發展文獻，並運用個案研究法、藉由半結構式（semi-structured）深度訪談後，以強弱危機分析（SWOT Analysis）個案機構、做出研究結果。 研究結果： 能正向促進服務團隊（或尚未加入計畫的醫事人員）參與意願的因素包括：有犧牲奉獻或充裕的醫事人員、行政程序簡化、資源交互支持、合理的支付金額或給付範圍、政策或服務宣導、醫療模式創新或照護習慣修正；病患及家屬接受居家醫療照護的考量，包括：獲得醫療服務的便利性、自行負擔之整體費用高低、風俗民情；支付金額或給付範圍未考量於偏鄉推動成本高，應提供具有針對性質的支付或資源。 研究結論： 機構未來需擴大服務區域（台東市、卑南鄉）、連結長照及他院出院準備服務部門、整併執行相關服務或計劃案、持續招募具服務熱忱的醫事人員、照護作業資訊化、指派專責護理師或個案管理師、對區域內弱勢病患提供費用補助、擴大社區合作機構（社區醫師、藥局、居家護理所）。 建構居家醫療照護需以患者為中心，由具凝聚力、能提供全面及協調照護的團隊執行，未來應朝減緩病患失能速度、實施健康管理等面向著手，以降低社會成本、讓病患在熟悉的環境中恢復健康、甚至走完人生最後一哩路。

Research purposes: This study has four purposes. The first purpose aimed to elucidate factors that will affect the willingness of the care service team, patients, and their family members to participate in the “National Health Insurance Home Medical Care Integration Plan (HMCIP)”. The second aimed to understand problems that may be encountered when implementing the HMCIP. The third aimed to analyze discrepancies between the amount and the scope of payment and the users’ willingness to pay. The fourth aimed to explore the willingness and the influencing factors of the medical staffs who have not joined the service yet. The fourth aimed to conduct strategies and assessments for the case agency on expanding their service in the future or enabling more medical staffs to join the home medical service. Research method: Literatures concerning the implementation and development of home medical care services in the United States, Japan, France, and Australia were reviewed extensively. We applied case study with a semi-structured in-depth interview to analyze the strength-weakness-opportunities-threats (SWOT) of the case organization for implementing the HMCIP. Research result: The factors that can positively enhance the willingness of the service team (or the medical staffs who are not included in the program) to participate HMCIP include: ample medical staffs with willingness to dedicate themselves, simplified administrative procedures, interactive resource supports, a reasonable amount or range of payments, policy or service promotions, innovation of medical care models, and correction of out-of-date medical care habits. The factors which may influence patients and their family members to join HMCIP include: convenience of getting medical services, costs of co-payment, and customs. The implementation of HMCIP has not considered the relatively high costs in remote areas. Our analysis suggests that targeted payments or resources should be provided in different areas. Analysis conclusion: In the future, the organization needs to expand its service areas (Taitung City, Beinan Township,) to link long-term care and discharge preparation services in other hospitals, to integrate related services or plans, to continue recruiting medical staffs with enthusiasm for service, to conduct the informatization of care operations, to assign specialized nurses or case managers, to provide cost subsidies for vulnerable patients in the region, and to expand community cooperation agencies (community physicians, pharmacies, home care centers.) Building home medical care requires a patient-centered cohesive team that provides comprehensive and coordinated care. We should make efforts to slow down patients’ disability, to implement health care management to reduce social costs, and to enforce patients to recover, or finish their last path of life, in a familiar and comfort environment.