出院準備服務之效果評估及影響出院後照顧模式之相關因素探討

The Effectiveness of Discharge Planning and Factors Affecting the Discharge Care Model

目的：出院準備服務計畫是一種集中式、協調性與跨專業領域醫療團隊服務的過程，透過醫療專業人員病患與家屬的共同合作，確保所有病患於出院後均能得到持續性的照護。本研究是比較出院準備服務介入與選擇照顧模式的差異。方法：本研究於2005年在北部某區域教學醫院，將符合高風險病患篩檢條件之199位病患分為介入組及對照組，介入組由居家護理師團隊進行訪查與出院指導，對照組則按照一般照顧模式，比較兩組的住院天數、一個月再住院率及急診率，並於出院三個月後進行滿意度的電話調查。結果：研究結果兩組之間住院天數、非預期的一個月再住院率及急診率沒有差異，介入組的滿意度則優於對照組。出院一個月後的照護模式主要為家庭照顧，其次為機構照顧及外勞照顧，不同照顧模式與個案身體功能有關，與介入組別、家人互動及經濟因素等無關。結論：出院後照顧模式的選擇主要受病患身體功能影響，本研究中的出院準備服務雖無法縮短住院天數，但可以提高主要照顧者或家屬整體的滿意度，有助於病患返家後持續性的照顧與相關資源的利用。

Purpose: Discharge Planning is an intensive, coordinated and multi-disciplinary care service. It is designed to ensure that patients receive continuous care through the collaborative efforts of hospital staff and patient families. Methods: This clinical trial was conducted in a regional teaching hospital in northern Taiwan in 2005. The 199 in-patients who met high-risk criteria were divided into an intervention group and a control group (100 and 99 cases, respectively). Patients in the intervention group received home care nurse-centered discharge planning and a home follow-up protocol. A satisfaction survey was administrated by phone three months after discharge. Results: The overall outcome suggested that there were no significant differences between the two groups in length of hospital stay, rate of readmission or emergency visits within one month. However, the intervention group showed a higher degree of satisfaction than did the control group. One month after discharge, most patients were cared for by family members and followed by foreign aid and institutions. The choice of care model depended largely on the physical function of the patients, family relationships and financial status. Conclusions: The major factor affecting the discharge care model was the patients' physical function. Discharge planning did not shorten the length of hospital stay, but it did increase the satisfaction of the patients and their families who received continuous care at home and used social resources.