探討以日間照顧服務為基礎的服務組合使用對機構入住風險與醫療利用之影響

Abstract

研究背景與目的： 隨著高齡人口的增加、扶養負擔逐漸加重與失能人口的上升促使長期照顧需求日益增加。對長期照顧服務使用者而言，自熟悉環境入住機構或護理之家時，需要適應新環境和新的生活作息而影響到其生理、心理與社會功能，所以實現在地老化，提供以社區為基礎的照顧服務相當重要。日間照顧服務為我國社區式照顧重要一環，能支持居家和社區個案的生活品質，幫助個案維持其生活，並達到在地老化的理念。然而過去研究顯示日間照顧服務對機構入住風險結果並不一致，此外，近年來台灣研究陸續探討多元的居家與社區式照顧服務使用成效，其中發現以日間照顧為基礎的社區式照顧有較高的機構入住風險，但是尚未有探究以日間照顧服務為基礎的不同服務組合對個案的機構入住與健康照護之影響。因此，本研究目標為一、探討使用日間照顧服務者使用其它服務的情形；二、比較不同日間照顧服務為基礎的服務組合對機構入住風險、醫療利用與費用的差異。 研究方法： 本研究為次級資料分析進行縱貫式研究，資料來源為串聯照顧服務管理資訊平台與衛生福利部資料科學中心之資料庫，篩選出2010至2013年期間，被核定日間照顧服務之65歲以上個案共4518人。並依據文獻回顧將研究對象劃分成三種以日間照顧服務為基礎的服務組合，分別是日間照顧組(2094人)、日照居家服務組(1773人)，以及日照居家醫療組(651人)。本研究使用多變項羅吉斯迴歸與多變項複迴歸分析，比較不同以日間照顧服務為基礎的服務組合，自初次核定使用長期照顧服務日期，追蹤第4至15個月的機構入住情形、門診、急診、住院與總費用是否有所差異。 研究結果： 個案平均核定2.13項服務，核定1項服務(即日間照顧服務)者占整體樣本44.05%，核定兩項服務者占了整體樣本的25.39%。其他服務核定比例為居家服務(28.66%)、機構喘息(27.38%)、居家喘息(20.63%)、居家物理治療(8.30%)、居家護理(7.08%)與居家職能治療(4.23%)。分組後，除了日照服務外，日間照顧組還有交通(4.97%)；日照居家服務組服務核定還有居家服務(49.69%)、機構喘息(49.41%)、和居家喘息(39.88%)；而日照居家醫療組則是還有居家服務(63.59%)、居家物理治療(57.60%)、機構喘息(55.45%)、居家護理(49.16%)、居家喘息(34.56%)、與居家職能治療(29.34%)。在控制其他變項下，日照居家服務組和日照居家醫療組相較於日間照顧組，機構入住的相對風險有較高傾向，但未達統計顯著差異。日照居家服務組和日照居家醫療組有使用門診的比例較日間照顧組低，但僅日照居家服務組相較於日間照顧組在門診使用風險較低，達到統計顯著差異(OR=0.549，p=0.0056)。日照居家服務組與日照居家醫療組在急診是否使用、急診使用次數、每次急診費用、累積急診費用、住院使用次數、每次住院天數與累積天數較日間照顧組高，但並未達顯著差異。進一步以性別與失能程度分層，發現男性在日照居家服務組有顯著較低的門診使用風險(OR =0.504，p=0.0288)，女性在日照居家服務組的每次急診費用(ß=404.6552，p=0.0059)、累積急診費用較高(ß=934.2360，p=0.0141)，女性在日照居家醫療組的每次急診費用(ß=457.1274，p=0.0340)顯著較高；輕度失能在日照居家服務組(OR=0.292，p=0.0049)與日照居家醫療組(OR=0.241，p=0.0276)有較低的門診使用風險，重度失能在日照居家服務組的門診使用次數較高(ß =3.6294，p=0.0338)，重度失能在日照居家醫療組有較低的住院使用風險，且達統計顯著差異(OR=0.665，p=0.0224)。 結論： 不同服務組合對不同健康與功能狀況使用者能維持相似的機構入住風險成效。相較於單一日照服務使用，多元服務組合對在輕度失能有效降低門診使用，對重度失能有明顯增加門診利用與減少住院利用效果。此外，女性在多元服務組合的急診使用較高也值得進一步探究。本研究期盼未來政策透過長照與醫療服務的連結，提供使用者更完善的日間照顧服務模式。

Background and Objective: Recent research in Taiwan has indicated that comparing to other patterns of services use, such as home-based services, community-based program service use patterns has higher risk for institionalization, which is not consistent with study findings from the western countries. To improve effectiveness, Taiwan’s adult day care programs were suggested to be further integrated with other long-term care services. This study aimed to (1) investigate the use of different long-term care services among care recipients who used adult day care services (ADS); (2) examine the effects of these different ADS-based service use patterns on care recipients’ nursing home admissions, health care utilization, and health care expenditures. Methods: We extracted cohort data from Taiwan’s first National 10-Year Long-Term Care Plan database and National Health Insurance claims data. The data included 33 types of long-term care services, including personal care, adult day care, and home respite care services, etc. We analyzed data from 4,518 older adults (65 years of age or older) who were first evaluated and prescribed adult day care services from 2010 through 2013. Seven types of long-term care services were grouped into three patterns of adult day care services use: adult day care (ADS; N = 2,094), day care-based personal care (day care-based PC; N = 1,773), and day care-based medical care (day care-based MC; N = 651). Multiple logistic regression and multiple linear regression were used to compare the impact of these service use patterns on nursing home admission and health care usage during the 4th to 15th months after initial evaluation for long-term care. Specifically, we compared the three groups’ risk of nursing home admission; use of outpatient visits, emergency department visits, and hospitalizations; and expenditures on outpatient visits, emergency department visits, and hospitalizations with covariates taken into consideration. Results: Among the 4,518 care recipients, the average services prescribed were 2.13 services each case. Among the overall sample, 44.05% were prescribed for one service, and 25.39% were prescribed for two services. In addition to adult day care service, home service (28.66%), institutional respite (27.38%), home respite (20.63%), home physical therapy (8.30%), home nursing (7.08%), and home occupational therapy (4.23%) were commonly prescribed to these older adults. For the adult day care group, transportation (4.97%) was commonly prescribed in addition to adults day care services; for day care-based PC group, home service (49.69%), institutional respite (49.41%), and home respite (39.88%) were commonly prescribed in addition to adults day care services; for the day care-based MC group, which included home service (63.59%), home physical therapy (57.60%), institutional respite (55.45%), home nursing (49.16%), home respite (34.56%) and home occupational therapy (29.34%) in addition to adults day care services. Compared to the ADS group, the day care-based PC group had a significantly lower of risk of outpatient visits (OR=0.549，p = 0.0056). People in the day care-based PC group and day care-based MC group tend to have higher emergency visits and fees, higher hospitalization admissions, days and fees, but no significant differences were observed. When the care recipients are male, the day care-based PC group had a significantly lower risk of outpatient utilization (OR=0.504, p=0.0288). When the care recipients are female, the day care-based PC group had a significantly higher emergency fees per visit (ß=0.504, p=0.0059) and emergency department fees (ß=934.2360, p=0.0141) ; the day care-based MC group had a significantly higher emergency fees per visits (ß=457.1274, p=0.0340). When the care recipients are at the stage of mild disability, the day care-based PC group (OR=0.292, p=0.0049) and the day care-based MC group (OR=0.241, p=0.0276) had a significantly lower risk of outpatient utilization. When the care recipients are at the stage of severe disability, the day care-based PC group have higher outpatient visits(ß=3.6294, p=0.0338) ; the day care-based MC group had a significantly lower risk of hospitalization admission (OR=0.665, p=0.0224). Conclusion: This study revealed no evidence to confirm that different patterns of adult day care–based services postpone nursing home admission. Multiple patterns of adult day care–based services had a significantly lower outpatient utilization for care recipients who are at the stage of mild disability, and had a significantly higher outpatient visits and lower hospitalization utilization. In addition, for female care recipients, multiple patterns of adult day care–based services had a significantly higher emergency fees per visits. Our study suggests that policymakers should provide the multiple services of long-term care and health care.