提昇腦中風病人出院返診追蹤率改善專案

Project for Improving the Follow-up of Stroke Patients

腦中風疾病復發重複入院將造成醫療費用、全民健保支出增加，甚而讓病人肢體殘障加重，臨床上常遇到腦中風病人未定期返診以致復發而再度入院的情況，故引發動機；本專案旨為提昇腦中風病人返診追蹤率達60%之改善，調查腦中風病人對於返診追蹤率偏低僅45%，其原因為疾病認知不足、家屬無法配合而未返診、轉介出院服務執行率低、忘記返診時間。經由明確之策略介入，包括運用衛教手冊、多媒體光碟、個案個別教導、團隊運作流程、增加電腦系統提示返診功能方案，結果返診追蹤率由45%提昇至68.65%。多元化之改善策略，可以有效達到預期目標，除了可讓病人定期返診追蹤以降低腦中風的復發率外，更可節省醫療成本，值得進一步推廣。

The recurrence of stroke and the readmission of stroke patients increase the cost of medical care and these events also result in patients becoming more handicapped. It is common that the stroke patients who did not have regular follow-up experience recurrent strokes and they are then readmitted to hospital. Therefore our study target was identifying ways of improving the rate of follow-up. Before the intervention, the rate of follow-up was only 45%. The reasons for this relatively low rate included misunderstanding of the disease, poor family support, a low level of use of the discharge planning service, and forgetting the date of follow-up visit. After target-oriented intervention in this study, the rate of followup improved from 45% to 69%. The methods used included public health manuals, a multimedia videodisc, case-by-case education, and the use of a computerized system to keep in touch with discharged patients. Using this multi-disciplinary approach, it was possible to reach the goal of improving the follow-up rate. A high follow-up rate ought to decrease the stroke recurrent rate and reduce the overall cost of medical care.