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標題: | 偏遠地區與非偏遠地區執行社區整體照顧模式及相關因子之初探 A Preliminary Study of Factors Related to Implementing the Integrated Community Care Service Model in Rural and Urban Areas. |
作者: | Chia-Yun Chang 張?云 |
指導教授: | 陳雅美(YA-MEI CHEN) 陳雅美(YA-MEI CHEN | chenyamei@ntu.edu.tw | ), |
關鍵字: | 社區整體照顧模式,整合機制,偏遠與非偏遠地區,長期照顧, Integrated community care service,Integrated mechanism,Long-term care,Rural and Urban Areas, |
出版年 : | 2022 |
學位: | 碩士 |
摘要: | 研究背景與目的: 全球面臨人口快速老化的問題,老年人常有多重慢性病或老年症候群,衛生體系必須有能力提供老人以個人為中心及整合照顧,我國亦自2017年開始推社區整體照顧模式,加強長照個案管理服務。許多文獻指出,整合照顧在減少機構入住、提升個案滿意度及增加資源可近性有相當的成效。偏遠地區普遍面臨資源缺乏的問題,整合照顧可以解決。因此本研究目欲探討偏遠地區相較非偏遠地區執行單位辦理社區整體照顧模式各面向整合機制之自評情形與相關因子。 研究方法: 本研究採用次級資料分析與橫斷性調查探討台灣偏遠地區與非偏遠地區之A個案管理單位(簡稱A單位)在辦理社區整體照顧模式自評之其各面向整合程度。運用國立臺灣大學陳雅美教授研究室所發展的整合工具「台灣長照整合機制自評問卷」the Taiwanese Self-Assessment for LTC Systems Integration (TwSASI)進行調查。問卷內容之的整合機制為組織整合、服務整合、資源整合及資訊整合等四大面向,以此為探討基礎。 次級資料:運用國立臺灣大學陳雅美教授研究研究室所回收之問卷資料(回收期間自110年4~10月),此階段對631個A單位發送問卷,回收之問卷共計260份,非偏遠地區回收235份,偏遠地區回收25份,整體回收率41.20%。調查研究:加強收集偏遠地區之單位,此階段106個A單位發送問卷,回收期間自110年10~12月,回收之問卷共計66份(網路回收49份、郵寄回收17份),排除非A單位或僅承接其他長照服務之單位(n=2),及未詳實填寫之單位(n=1),非偏遠地區回收9份,偏遠地區回收54份,整體回收率59.43%。 最後,除去其中與次級資料重複的單位(n=23),本研究合併次級資料語調查資料最後整體的回收非偏遠地區之回收率為40.00%(210/525)、偏遠地區之回收率為54.72%(58/106)。除五個面向整個機制自評之外,也納入共變項包括單位屬性、區域別、個案數、個管師數及其專業背景人數、單位個管師平均工作年資、身分別、單位服務年資、合作B、C單位數及資訊聯繫平台。分析方法以雙變項分析檢定相關因子的與地區別、各面向整合機制的關係。多變項線性迴歸分析探討整體、偏遠及非偏遠地區對各面向整合機制之影響。將偏遠地區、非偏遠地區分兩組進行分層分析,以探討不同地區別影響各面向整合機制之影響。 研究結果: A單位以私立單位(79.10%)、醫療相關機構(49.63%)為多,填答者的以非主管居多(60.45%)。個案數、個管師數、合作B單位數、C單位數非偏遠地區均比偏遠地區多。工作年資部分偏遠地區皆比非偏遠地區長。在通訊平台方面,使用line聯繫為第1位。比較偏遠地區及非偏遠地區有差異之因子共6個,包括單位屬性1(p=0.001)、區域別(p=0.001)、個管師背景為社工師的數量(p=0.004)、個案聯繫平台之其他達顯著差異(p=0.020)、個案數(p=0.001)及合作B單位數(p=0.013)。 自評各面向整合機制之程度,資源整合之平均值4.02(SD=0.55)最高、資訊整合之平均值3.66(SD=0.67)最低。非偏遠地區及偏遠地區,非偏遠地區之資源整合之平均值3.97(SD=0.56)最高、資訊整合之平均值3.63(SD=0.65)最低。偏遠地區之資源整合之平均值4.21(SD=0.47)最高、資訊整合之平均值3.78(SD=0.74)最低。其中偏遠地區資源整合自評分數有顯著高於非偏遠地區(p=0.004)。 在控制共變項後,整體A單位各面向整合機制之多變量分析顯示除資源整合外(β=0.154、p=0.033),偏遠與非偏遠地區並非影響整合機制之相關因子。使用組織聯繫平台之政府系統(β=0.132、p=0.037)及組織間不使用”其他”方式聯繫(β=-0.145、p=0.029)其組織整合程度越高;個管師背景其他職類之數量越多,服務整合程度越差(β=-0.167、p=0.015);偏遠地區自評資源整合程度顯著高於非偏遠地區(β=0.154、p=0.04)。非偏遠地區及偏遠地區分層進行A單位各面向整合機制之多變量分析,非偏遠地區中,合作B單位數越少其組織整合及整體整合程度越高(β=-0.164、p=0.027)、(β=-0.156、p=0.037)。有使用組織聯繫平台之e-mail其組織整合程度越高(β=-0.183、p=0.012)。偏遠地區中,身分別為主管自評資源整合程度較高(β=0.316、p=0.018);個管師數越多,組織整合越差(β=-0.333、p=0.005);私立單位較公立單位之資訊整合程度差(β=-0.266、p=0.041)、組織間使用”其他”方式聯繫則資訊整合程度越差(β=-0.405、p=0.005)。 討論與結論: 本研究結果發現偏遠地區除在資源整合程度外,並非各面向整合機制的相關因子,顯示現行長照個案管理政策之推動無明顯城鄉差距。偏遠地區及非偏遠地區影響整合機制之相關因子不同,非偏遠地區為組織間使用e-mail聯繫、合作B單位數等;偏遠地區為主管身分、個管師數、公私立單位及組織間使用其他方式聯繫。 對政策之建議有不同地區別各面向整合機制之推動有不同的策略、推動偏遠地區資訊平台的建置,強化偏遠地區私立單位資訊整合的能力及A單位內部的溝通機制以及培訓規劃。對未來研究之建議為探討資訊平台的使用方式之影響、偏遠地區A單位與不同類型與數量長照資源的整合對照顧結果之影響、偏遠地區是否更合適聚焦非多元長照專業服務發展以利服務整合。 Background: Aging population is a global challenge. The health care system must able to provide coordinated and integrated care to older adults with chronic disease or geriatric syndrome, Taiwan promoted the integrated community care service in 2017, strengthen the Case Management service. Many research studies indicated that integrated care improve user experience reduce nursing home admission, and improve accessibility. This research compared the level of integration perceived by care managers in rural and urban areas and related factors. Methods: This research used secondary data analysis and conducted cross-sectional study to investigate the level of integration self-appraised by tier A care management centers (referred as Tier A center) using the Taiwanese Self-Assessment for LTC Systems Integration (TwSASI). TwSASI including four domains: inter-entity planning and management, care coordination, integrated resources and integrated information system. Target population was 631 tier A centers in Taiwan. The data was collected in two steps. The secondary data analysis: Data was collected by National Taiwan University Professor Ya-Mei Chen’s research team (During April to October,2021). The secondary data totally 631 questionnaires were sent out, and 260 returned with a return rate of 41.20% ( 235 from urban area、25 from rural area ). The Survey Research: A total of 106 questionnaires were sent out to rural area tier A care management centers, and 63 returned (During October to December,2021) with a returned rate of 59.43% ( 9 from urban area、54 from rural area ). After combining data from the two data sources, 268 tier A care management centers returned information with 210 and 58 from urban and rural areas ( return rates for urban area was40.00%, and 54.72% for rural area ). The dependent variables are five integrated mechanism self-appraisal scores, and the covariate variable include unit types, locations, case numbers, number of case managers, average work years, average work years of A case manager, work supervisor, b numbers, c numbers and information system. We use two sample t-test, Chi-Square Test, and One-way ANOVA test to examine the relation in five integrated mechanism and related factors between rural and urban areas. We use multiple regression analysis to examine rural-urban differences in the five integrated mechanisms self-appraisal scores with covariates controlled. We also Stratified our analysis by rural-urban areas. Results: Most of the tier A management centers are private unit (79.10%), health care facilities (49.63%), most respondents were not leaders (60.45%). There were more case numbers, number of A case manager, number of tier b professional centers and c centers collaborated. For the average working years, care managers at the tier A care management centers were longer in rural areas. LINE was the most commonly used instrument to communicate. The level of integration self-appraised by tier A care management center. The highest average score was integrated resources with 4.02 points (SD=0.55), the lowest average score was integrated information system with 3.66 points (SD=0.67). In urban area, the highest average score was integrated resources with 3.97 points (SD=0.56), the lowest average score was integrated information system with 3.63 points (SD=0.65). In rural area, the highest average score was integrated resources with 4.21 points (SD=0.47), the lowest average score was integrated information system with 3.78 points (SD=0.74). After controlled the covariate variable, there were no significant differences in urban and rural areas except Integrated resources (β=0.154、p=0.033). For all tier A management centers, those use government system showed higher inter-entity planning and management integration scores (β=0.132、p=0.037); those use “other information platform” to communicate showed lower inter-entity planning and management integration scores (β=-0.145、p=0.029). Those A case manager centers with more case managers as “others” showed lower care coordination integration scores (β=-0.167、p=0.015). The average score of integrated resources in rural areas was significantly higher than in urban area (β=0.154、p=0.04). For tier A management centers in urban area, those collaborated with more tier b professional centers, showed lower inter-entity planning and management integration scores (β=-0.164、p=0.027), and lower scores in all dimension of integrated mechanism integration scores (β=-0.156、p=0.037). Those used e-mail to contact between organizations showed higher inter-entity planning and management integration scores (β=-0.183、p=0.012). For tier A management centers in rural area, when the respondents were work supervisors, they showed higher integrated resources integration scores (β=0.316、p=0.018). The higher number of case managers in tier A management centers, the lower inter-entity planning and management integration scores (β=-0.333、p=0.005). Those undertook by private units (β=-0.266、p=0.041) and used “other information platform” to contact between organizations (β=-0.405、p=0.005), showed lower integrated information system integration scores. Conclusion: The current study findings indicated that the levels of self-appraised integrations were similar between rural and urban areas. Factors contributed to implementing the Integrated Community Care Service Models differ from rural-urban areas. In urban areas, the factors contributing to levels of integrations were numbers of B professional centers collaborated and using e-mail to contact between organizations. In Rural area, the factors contributing to levels of integrations were work supervisor, numbers of care managers, tier A management centers undertook by public or private units, and using other-ways to contact between organizations. We suggest that different strategies for promoting integration in rural and urban areas. For urban area, encourage tier A management centers using e-mail to contact between organizations. For rural area, building information system, and strengthening integrated information system integration in rural area is strongly recommended. Enhance communication between tier A management centers and arrange training program. For future researches, the impacts of different information systems on the outcomes of integration, types or numbers of long-term care services that collaborated with tier A care management centers and related outcomes merited further studies. |
URI: | http://tdr.lib.ntu.edu.tw/jspui/handle/123456789/83523 |
DOI: | 10.6342/NTU202203406 |
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