長期照護照顧管理人力資源耗用之研究

Abstract

研究目的: 我國為了加強老人的照顧，行政院於2007年核定「我國長期照顧十年計劃」，參考歐美先進國家的經驗，在我國25縣市均設立「長期照顧管理中心」，希望能夠將「照顧管理」制度推廣至全國，以建構完整的長期照護體系。文獻顯示，長照中心照顧管理專員為照顧管理制度的重要靈魂人物，然而目前沒有台灣本土的相關研究深入探討照顧管理專員實際的照顧管理工作內容以及照顧管理人力資源耗用的情形。由於嘉義市為我國第一個社區長期照顧管理制度介入計劃的實驗社區，所屬之長照中心亦是目前各縣市長照中心建置照顧管理制度的重要參考指標，因此本研究希望能以嘉義市長照中心照顧管理專員的實務經驗以及長照服務的個案實證資料，進行以下三個研究目的探討:一、分析照顧管理專員的服務內容二、分析照顧管理人力資源耗用的情形三、檢驗影響照顧管理人力資源耗用的因素，期望能成為我國長期照顧管理制度發展之參考依據。 研究方法: 本研究對象為2010年1月1日至2010年7月31日止嘉義市長期照顧管理中心曾經接受照顧管理服務的個案，共702位個案。資料來源則為個案服務紀錄表以及個案評估量表。先以內容分析法剖析個案服務紀錄表中，照顧管理專員針對服務個案所執行的各項照顧管理工作內容與時間，而後串連每位個案的評估量表資料，再以線性複回歸方法進行照顧管理資源耗用影響因素的分析。 研究結果: 依據分析結果，照顧管理專員所執行的照顧管理工作內容可分為七大類:包括轉介個案、評估需求與照護計畫擬定、服務與資源的連結、追蹤與監測、問題的解決與衝突的處理、結案以及行政工作，其中以服務與資源的連結以及評估需求與照護計畫擬定等兩大類工作，最為頻繁也花費最多時間，共耗用了照顧管理專員將近90%的照顧管理工作時間，然而在「追蹤與監測」工作，所佔的照顧管理工作比率只占3.59%。 在個案所耗用的照顧管理資源分析發現，帄均每人耗用總照顧管理工作次數為7.65次，平均每人耗用總照顧管理時間則為192.0分鐘，其中有將近四分之一的個案總共只耗用全部個案13%的總照顧管理工作時間，然而卻有10%的個案耗用全部個案總照顧管理工作時間的三分之一，顯示有少數個案耗用大量照顧管理資源。 複迴歸分析發現，在控制其他變項後，一般戶的舊個案、失能程度越嚴重、有憂鬱情形、有服務提供單位相關問題的個案、家中有其他長期照顧需求者、有主要照顧者照護問題以及由3號與6號照顧管理專員所服務的個案會耗用較多的照顧管理資源。其中有「問題行為」與「認知障礙」的個案在假說中認為是影響照顧管理資源耗用的因素，惟在本研究中，並沒有呈現統計上的顯著差異。 討論與建議: 一、照顧管理工作的時間分配不均:研究發現「追蹤與監測」照顧管理工作執行的比率過少，分析原因包括個案服務紀錄表漏填以及個案負荷量與業務量過多所造成。二、少量個案耗用大量照顧管理資源:這些耗用大量照顧管理資源的個案多半為失能程度較為嚴重的個案，顯示長照服務資源多為以提供失能者的社會支持服務為主，對於有多種複雜的健康照護問題個案，缺乏醫療照顧設計。三、照顧管理人力資源耗用的影響因素:研究發現由於照顧管理專員欠缺「問題行為」個案的評估與處理訓練，加上目前給予民眾的長照服務資源中，亦無法滿足認知障礙個案所需的照顧需求，使得此兩項因素對於目前照顧管理資源的耗用沒有造成顯著影響。四、個案未接受例行性覆評之討論:研究中發現，有176位個案未接受例行性的覆評，分析原因為覆評工作耗時且繁雜，因此照顧管理專員在業務量的負荷下，只針對需要再繼續提供服務的個案進行覆評的工作。 根據以上問題，本研究提出以下的政策建議包括一、重新檢討照顧管理人力結構與照顧管理專員的工作內容ぼ二、建立照顧管理服務工作的流程規劃與品質改善包括重新檢討覆評的時機與方式，發展個案複雜度篩選評估表以及建立照顧管理專員「追蹤與監測」照顧管理工作的流程與稽核機制三、加強照顧管理專員的訓練與能力包括問題行為個案的評估與處理訓練以及認知障礙個案「資源開發」能力四、結合健保資源，加強複雜健康個案的長照服務五、重新檢討照顧管理專員的績效考核與個案負荷量。

Research Purposes: To reinforce the care for the elderly, the Executive Yuan has approved the Ten Years Long-term Care Program in 2007 and established 25 long-term care management centers in each city among Taiwan, hoping to provide integral and appropriated long term care services through case management system. Care managers are the key persons to provide professional services of case management. However there is no relevant researches on the analyzing the care managers’ actual content of case management practice, nor the local researches discussing the care manager resource utilization in long-term care. The objectives of this thesis are as follows: (1) to analyze the care manager’s actual case management services; (2) to analyze the care manager resource utilization and (3) to explore the important factors affecting the care manager resource utilization. Research Method: The study subjects are from long-term care management center in Chiayi City who received case management services between January 2010 and July 2010. Total of 702 cases were enrolled in the current study. Sources of information included case service utilization logs and case assessment scale. In the begging, content analysis of case service utilization logs were use to collected different categories of case management services and time required according to each service. After that combined with the case assessment scale, multiple regression analysis were performed to examine the determinants of care manager resource utilization. Research Results: After analysis, seven categories of case management services performed by the care managers included: (1) case referral; (2) need assessment and care planning ;( 3) connecting services and resources; (4) monitoring ; (5) problem solving and handling conflict ; (6) case closing and (7) administration work。Among the services, need assessment and care planning together with connecting services and resources are considered the most frequent and time consuming services which took care manager’s 90% of total case management time. However, care managers only spent 3.59% of the case management time in monitoring cases under long-term care service. Regarding the care manager resources utilization analysis, the results showed that the average case management work number required for each case is 7.65; and the average case management time required for each case is 192.0 minutes during the study period. There were one fourth of cases consuming only 13% of total case management time while 10% of cases consuming 33.3% of total case management time. This result indicated that only few cases consuming large amount of case management resources. A multiple regression analysis reveals the determinants of care manager resource utilization. Cases with the following factors would consume more case management time including old cases, severe functional impairment, cases with depression, conflict with service provider, caring problem with caregiver ,with other long-term care need members in the family, and cases received the services from number 3 and number 6 care managers. However although in our hypothesis cases with problem behavior and cognitive impairment would affect case management resource utilization, both of them did not reach statistically significant in our study. Discussions and Conclusions: (1) Uneven distribution of time spent for different case management work: our study revealed that care manager spent less amount of time in monitoring cases who received case management services. The reasons included incomplete case service utilization logs and heavy case loads. (2) Few cases consumed large amount of care management resources: our study results revealed that cases consuming large amount of care management resources were belong to severe functional impairment cases which indicated that the current long-term care services are mainly social support services. There is short of medical care services for cases with complicated multiple health problems. (3) Factors affecting care manager resource utilization: Cases with problem behavior and cognitive impairment are the two factors in our hypothesis which would affect care manager resource utilization. However due to the lack of training and capabilities for assessing and handling problem behavior cases together with the current long-term service unable to meet the need of cognitive impairment cases, these two factors were not shown statistically significant in our study. (4) The discussion of cases without routine re-assessment: In our study we found 176 cases did not receive routine re-assessment. It is because that the re-assessment is considered as time consuming and complicated work, under the pressure of large amount of case load, care managers would only choose certain cases for the re-assessment. Policy implications of this study are the following: (1) Re-evaluation the case management manpower structure and the work content of care managers. (2) Establish coherent case management service guidelines focus on the timing for re-assessment of the cases and developing screening scales for complicated cases. Establish quality improvement system for care manager’s case management services such as monitoring cases. (3) Increase case manager training programs to include both assessment and management of problem behavior cases and resources development capability especially for cognitive impairment cases. (4) Combine resources of health care and social services to enhance the long term care for complicated multiple health problem cases. (5) Re-evaluation the standards of performance assessment and case load for care managers.