探討照專及個管對長照區域整合機制自評落差

Abstract

研究背景與目的：2017年長照2.0推出時，強調與長照1.0很大的不同在於「整合」，而社區整體照顧模式為長照服務體系裡個案管理模式的重大突破，隸屬公部門的照顧管理專員(簡稱照管專員)角色從照顧管理轉變成失能評估，而服務連結由民間單位成立的A個案管理員(簡稱A個管)負責，因此社區整體照顧體系推動成敗取決於照管專員與A個管的合作成效，雙方對於整合的認知及目標若一致，必有助於合作推動。因此本次研究主要探討A個管及照管專員對於現行長照整合執行程度的認知是否相似，並討論服務年資、個案數、服務縣市及是否為主管職等因子是否會影響A個管及照管專員對長照整合執行認知的標準。 研究方法：本研究為次級資料分析合併橫斷式調查研究設計。A個管組問卷採次級資料分析，由陳雅美教授研究室團隊提供；照管組部分以問卷方式調查北部某三縣市照管專員對於目前長照整合的執行程度評分，以匿名、自填方式收集紙本或線上問卷。本研究使用陳雅美教授團隊所發展之「台灣長照整合機制自評問卷」，問卷以Evashwick(2005) 提出的整合要素，包括組織整合、服務整合、資源整合及資訊整合四大調查面向、共34小題。問卷內容整體信度達良好信效度。本問卷以李克特5點量尺計分，分數越高表示認為該項執行程度越高。本研究探討照專與A個管在整體整合、組織整合、服務整合、資源整合及資訊整合等面向認知是否有不同。控制因子包括服務年資、個案數、服務縣市及是否為主管。資料收集後以SAS 9.4進行分析，探討A個管與照管專員的身分對整合執行認知是否一致，以及探討不同身分別，工作年資、個案數、服務年資及是否為主管如何影響對A個管與照專的長照整合執行程度之認知。 研究結果：本次共分析A個管組問卷76份、照管組問卷93份，平均年資為A個管組2.39 年、照管組3.94年 (p<0.0004)；平均個案數A個管組122.4案、照管組308.6案(p<0.0001)；服務縣市部分，三個縣市的填寫人數具明顯差異(p<0.0001)；非主管填寫人數明顯高於主管 (p<0.0001)。整體而言，在組織整合、服務整合、資源整合及資訊整合4個面向的整合執行程度裡，照管組各面向得分(3.40~3.59)都顯著低於A個管組(3.79~3.98) (p<0.0001~p=0.0168)。在多元線性回歸分析中，控制共變項下，全整合面向部分，照管專員整合執行程度分數比A個管低0.38分(p=0.0022)；組織整合面向部分，照管專員整合執行程度分數比A個管低0.43分(p=0.0028)；服務整合部分，照管專員整合執行程度分數比A個管低0.42分(p=0.0032)。且照管專員每多一年服務年資，整合執行程度降低0.04分，每多服務一名個案，整合執行程度些微上升(p=0.0442)；在資源整合部分，照管專員整合執行程度分數比A個管低0.54分(p=0.0008)；在資訊整合部分，A個管組每多一名個案，資訊整合執行程度分數就些微降低(p=0.0066)，且B縣市整合執行分數顯著比A縣市低0.56分(p=0.0223)。 討論與結論：研究結果發現，A個管與照管專員對於現行長照整合執行認知具明顯差異，A個管組分數普遍比照管組高。推測A個管對於自己業務工作成果滿意度較高，而照管專員對於整合執行要求標準較高。這樣差異可能來自照管專員及A個管的資格訓練內容。A個管整合概念相關之課程時數較照專少，故推測可能是A個管基礎訓練中整合的理論訓練不足，以至於A個管缺乏整合概念，繼而影響A個管對整合執行運用及標準。本次研究亦發現2個現象，(一)年資有助照管專員累積服務整合的經驗，但在A個管部分卻沒未見這樣結果。比較照管專員及A個管的資格訓練內容，發現A個管資格訓練缺乏整合概念實際運用的練習，推測可能是A個管可能是基礎訓練中整合概念的訓練不足，以至於A個管缺乏整合概念及實作機會，日後實際執行A個管業務時，若無他人指導或透過個案討論等實務經驗分享，恐難以累積服務整合得經驗，導致工作年資久也無法累積服務整合的經驗。(二)A個管的個案數越多，覺得資訊整合的執行程度越低，但是照專沒有此現象。推測原因為A個管協助每一位個案的服務輸送、服務調整時都需與多單位、大量的訊息交換，故當個案數越多時，越仰賴完善之平台去達到有效的橫向溝通。綜上所述，建議未來強化照顧服務管理資訊平台內個案管理功能、增加跨專業討論媒介，及修訂A個管資格訓練內容，加強整合之概念及實作演練，特別是在服務整合的部分，並鼓勵長期照顧管理中心承擔起對A單位之輔導角色，提升A個管跨服務、跨專業之運用能力，落實整合之理念，應是未來長期照顧服務品質的重要方向。

Background：When the long-term care 2.0 (LTC 2.0) policy was launched in 2017 with great emphasis on 'integration'. A major breakthrough in the case management model in the LTC 2.0 was adding case managers to share care managers’ workload.. The role of the care manager in public sectors has changed from care management to disability assessment only, and the service link is provided by the case manager from private sectors. Therefore, the success of the case management services in the community depends on the cooperation between the care manager and the case manager. Whether the two professionals have the same level of knowledge in integration may be a critical issues. The current research explored and compared the level LTC services integration percieved by the care manager and the case manager, as well as exploring factors contributing to the level of LTC services integration perceived by care manager and case manager. Methods: The research was a secondary data analysis and cross-sectional survey design. The data regarding the levels of LTC services integration percieved by care managers was collect by the Professor Ya-mei Chen’ research study. The current study further collect data regarding the levels of LTC services integration perceieed by case managers in three countries in Northern Taipei through cross-sectional survey, both through mailing and internet survey. This study used the 'Taiwanese Self-Assessment for Long-term Care Systems Integration (TwSASI) ' developed by the research team of Professor Ya-mei Chen, which showed good validity and reliability. Four types of integration by Evashwick (2005) was included in the data for analyses and surveys, which included levels integration in the (1) overall integration; (2) organization integration, (3) service integration, (4) resource integration, and (5) information integration, A total of 34 questions were included. The questionnaire is scored on a 5-point Likert scale, the higher score refers to a higher degree of implementation of the item. SAS 9.4 was used for analysis. In addition to descriptive analyses, independent sample T-test, Pearson correlation, ANOVA were used for bi-variate analysis. Multiple Linear Regression was used to compare the perception of the level of LTC integrated between care manager and case manager with covariates adjusted. Factors like self-identities, seniority, number of cases, service cities, and a supervisor or not were included as covariates. Results: A total of 76 questionnaires in the case manager group were included for analysis and 93 questionnaires in the care manager group were returned. The average number of years of experience was 2.39 years for the case manager group and 3.94 years for the care manager group (p<0.0004); the average number of cases was 122.4 for the case manager and 308.6 for the care manager group (p<0.0001); there was a significant difference in the three service cities (p<0.0001); the number of non-supervisors was significantly higher than that of supervisors (p<0.0001). With covariates controlled, the levels overall integration aspect, the care manager group perceived 0.38 points lower than the case manager group’s scores (p=0.0022); the levels organization integration aspect, the care manager group perceived 0.43 points lower than the case manager group’s scores (p=0.0028); the levels service integration aspect, the care manager group perceived 0.42 points lower than the case manager group’s scores (p=0.0032); The level of integration in service integration aspect perceived by the care manager is reduced by 0.04 points for every additional year of service years (p=0.0042). For every extra case, the level of integration in service integration aspect perceived by the care manager increased slightly(p=0.0442). The level of integration in resource integration aspect perceived by the care manager group was 0.54 points lower than that of the case manager group (p=0.0008). The case manager group perceived decreased level of integration in information integration aspects for every extra case(p=0.0066). The integration implementation score of city B was significantly lower than that of city A by 0.56 points (p=0.0223). Discussion: The results of the study showed that there was a significant difference in the perception of the level of long-term care service integration between the case manager and care manager. The scores of the case manager was higher than that of the care manager group. It could be due to the higher the standard of integration implementation by the care manager group. Comparing the qualification training content for the care managers and the case managers, the course hours related to the integration concept for case managers are relatively low. It is possible that basic theoretical training for integration for the case manager may be insufficient. As a result, the case managers may lack the concept of ideal integration, which in turn affects the case manager’s evaluation and standards of the level of the LTC serivces integration they have provided. This study also found 2 phenomena:(1) Seniority helps care managers accumulate experiences in integration service, but not for case managers. This could be again due to the lower training hours for integration among case managers. With limited training in the concept of integration, it may be more difficult for a case managers to accumulate experiences in providing integrated integration. (2) The more cases that a case managers have, the lower levels of information integration they have perceived. It is possible that the work of case manager involved exchanging and coordinating information with multiple organizations while arranging service delivery and adjustment for every case. Therefore, when the number of cases increases, the more a need for case manager to have a good information platform to achieve effective communication. To sum up, it is recommended to strengthen the case management function in the care service management information platform in the future. Also, increase the interdisciplinary discussion and revise the content of qualification training for case managers and strengthen the concept of integration and practical drills, especially in service integration aspect. The long-term care management center managed by the governments was also encouraged to assume the role as a mentor for care managers within the same jurisdiction. Enhancing the case manager's interdisciplinary application ability, and implementing the concept of integration shall be a priority for future LTC service quality.