整合性照顧系統

Integrated Care Systems

專業主義的發展使得健康照顧服務間易呈現重疊、落差或不易銜接，影響使用者不易獲得持續性照顧；慢性病症的照顧需求隨著人口高齡化程度而增加，整合性照顧遂被提出成為因應高齡者及慢性疾患者照顧需求的重要概念之一，以提高服務的可近性、管理服務品質以及有效控制成本。本文主要在描述整合性照顧的意涵、理由、模式、優勢與限制論述，並簡述美國、加拿大、日本以及我國等四個國家的整合性照護案例，最後提出建議護理專業策略性地培育準備不同層級人員的能力，例如學士層級者具有慢性病症管理能力，碩士層級護理人員具備個案／照顧管理能力，博士層級護理人員具有參與決策以及規劃、推動策略能力，因應整合性照顧之策略需求，回應高齡化社會之照顧需求。

The development of professionalism in the health care industry has resulted in the existence of distinct lines of demarcation between disciplines. Duplication or absence of services, or lack of connection between services has made it difficult to respond to the needs of people with chronic conditions. With the rapid growth of the population with such conditions, the concept of integrated care has been proposed in order to increase accessibility, quality of care, cost sustainability and user satisfaction for such patients. The main content of this paper includes a definition of integrated care, the rationale behind it , and a model for it, as well as the advantages and disadvantages associated with it. Four integrated care systems were selected from different countries: Social HMO and PACE from USA, SIPA from Canada, Japan's community support system and Taiwan's long-term care resources management centers. Recommendations are also provided for members of the nursing profession actively participating in integrated care systems.