嘉義市長期照顧管理制度之建置策略與成果

Abstract

研究目的：由已開發國家之長期照護改革政策可知，照顧管理制度在整合長期照護服務網絡中扮演相當重要的角色。我國在2000年行政院核定「建構長期照護體系先導計畫」(簡稱先導計畫)，以實驗社區結合實務與研究，首次建立我國社區長期照顧管理制度，因此具有相當重要參考價值。因此本研究希望能以先導計畫之執行經驗及其實證資料進行以下兩個研究目的：一、探討建置照顧管理服務，重要面向之執行策略及其困難或問題；二、探討照顧管理服務制度建構後，對個案及其家庭照顧者所造成之影響。 研究方法：本研究資料來源為2000年由台灣大學執行『建構長期照護體系先導計畫』，同時採用質性及量性研究方法進行，依據本研究目的，分別以嘉義市實驗社區及其個案為研究對象，前者採用個案研究法，資料來源包含實驗社區之相關文件、檔案紀錄及訪談等；後者串聯個案評估量表、個案處理過程表、服務印領清冊、後測調查問卷及後測照顧管理評估問卷等資料，以邏輯斯複回歸、存活分析等進行服務使用影響因素及照顧結果影響因素之檢驗。截至2003年5月底，照顧經理已接觸2,337位個案，其中有985位為照顧經理評估需要照顧管理之個案，其中實際曾接受服務有477位。 研究結果： 建構社區照顧管理制度重要且可行之策略如下： (一) 從行政與組織面向來看，應利用中央與地方統一決策指揮單位的建立，以專案小組實際執行任務。 (二) 為發展多元化社區服務資源與連結，透過擴大服務給付範圍、次數及服務對象，鬆綁法規、引進技術指導並予以輔導、補助服務開發之設施設備與人事費用等，提供有利社區長期照護服務發展之環境。 (三) 建立照顧管理制度準則，及照顧經理之職前教育與訓練計畫；跨專業團隊之專家會議溝通，對於建立照顧管理作業模式也相當有助益。 (四) 財務需統籌服務資源與補助經費，且由照顧經理擔任資源配置的守門員，把關照顧資源，並利用部分負擔機制來避免服務浪費。 (五) 擅用多元化的宣導溝通方式，推廣服務，如利用地方基層領袖、社區公告、或醫療網絡等宣傳管道。 985位接受評估的個案，有477位(48.4%)接受照顧經理建議之服務，其中50.7%接受兩種以上服務，平均使用5.7個月。分析結果顯示個案年齡較大、高社經、缺乏家庭照顧資源、照顧需求高、家庭照顧者有專職工作、身體照顧負荷大者，較會接受照顧管理服務，這些族群可作為未來照顧管理制度介入之目標族群參考。 這些接受照顧經理評估的個案中，個案(OR=1.183)及家庭照顧者(OR=1.313)對照顧經理的感受是影響接受服務的顯著因素，感受越正向也越容易接受服務。接受服務之個案身體功能較能夠維持(OR=1.437)，存活率(OR=2.958)較高及存活天數(RR=2.022)也顯著較多，但個案合併認知功能障礙，則會減少存活天數(RR=1.703)，未來應進一步探討原因。此外，照顧管理服務的使用並未顯著降低住院率。在照顧管理服務過程評價方面，則發現評價越高，家庭照顧者之整體滿意度(OR=0.455)較不會變差，照顧負荷(OR=0.466)也會較低。 討論與結論：整體而言，照顧管理服務對於身心功能障礙者的健康，及其家庭照顧者的協助具有正向之影響。本研究之結果中所建議之建置策略，可提供有利照顧管理制度建置環境，使服務能擴散到所需民眾。除此之外，為確保制度能持續運作，應在體系中給予照顧經理正式的職位，每年編列預算維持照顧管理服務的提供，並予以整合服務的自主性；也應建立證照及品質控制機制。

Research Purposes: Care management has played a significant role in integrating long-term care services in developed countries. In Taiwan, it was implemented in a community-wide experiment under the “Pilot Project for the Establishment of Long-term Care System” in 2000. The aims of this study are 1) to assess the strategies used in implementing the care management scheme, and 2) to assess the effects of care management on the disabled and their caregiver. Research Method: Quantitative and qualitative data from the pilot project (Chia-Yi City) was used in this study. A total of 2,337 subjects were contacted, 985 of them were deemed in need of care management, and 477 of them ended up using long-term care services through the care management scheme. Sources of information included archive records of meetings, survey questionnaires, work-logs, service utilization logs, and other relevant documents. Multiple logistic regression and survival analysis were performed to examine the determinants of service utilization and the outcome of services. Research Results: Review of documents show that effective strategies for implementing a care management scheme in a new community includes: (1) Establishing a streamlined decision making body incorporating both the central and local government, and working with a task force to carry out the actual implementation activities. (2) Creating an environment that would encourage the development of services through broader coverage of services by public funding, subsidy for physical infrastructure, hardware, and personnel, and the infusion of technical aspects of care. (3) Establishing a protocol of care management and conduct educational and training programs for the care managers. Working with an inter-disciplinary committee of long-term care services would be helpful. (4) Installing the concept of co-payment in the system and use care managers as the gatekeeper of services. (5) Utilizing a multi-channel approach to promote the services, such as through the local opinion leaders, community bulletins, or hospital networks. Among the 985 subjects who received the assessment, 477 (48.4%) of them received the services suggested by care managers, 50.7% of them received more than two kinds of services, and the use the services was 5.7 months on average. Statistical analysis shows that being older, higher socioeconomic status, more needs, caregiver who has a full-time job, and higher physical burden were more likely to receive services. These groups could be valuable reference for the target groups of management system intervention in the future. Among those who have undergone a need assessment, the positive perception of the disabled and the family caregiver towards the care manager are significant predictors of service use. Those who have received the services seemed to survive longer, and more likely to maintain their ADL functions. However, care management has no effect on hospitalization. For those with cognitive impairments, under care management seemed to decrease their survival time. Further analysis is needed. Regarding satisfaction with services, care management tends to increase the overall satisfaction and decrease caregiver burden. Discussions and Conclusions: In this study, care management had demonstrated positive effects on the health of the disabled and the well-being of the family caregivers. The strategies recommendations listed in the result section can provide a conducive environment for its diffusion. In addition, to ensure its continual operation, the infrastructure of care management should be formalized by giving care manager official titles and positions in the system, allocating annual budgets to the provision of care management, and allowing full authority to integrate services. Licensure and other quality control mechanism should also be established.