高齡醫療服務的發展－—由片斷走向整合

Healthcare Services for Older People: From Fragmentation to Integration

我國65歲以上老年人口預計在2025年時突破20%，成為「超高齡國家」，如此快速的人口老化趨勢在人類歷史上是前所未見的現象，也衍生前所未有的挑戰。高齡者的健康特質與一般成年人有根本上的差異，特別是身心失能對於長者的健康有根本上的關鍵影響，因此，在提供醫療健康服務時必須要特別關注多重共病與身心失能間的關聯，而歐洲最近十年來大力推動跨越衛政與社政體系的整合照護，已然成為歐盟社會安全的重要基石。我國高齡者健康照護的服務從門診、住院、中期照護與長期照護來看均未臻理想，期間充滿了片斷化的醫療服務內容，對於具有多重疾病與身心失能的長者而言，不僅造成就醫的不便之外，還嚴重影響了照護品質與病患的生活品質。以現況而言，我國目前針對高齡者的健康照護已發展出各種服務模式，包括門診整合、高齡友善健康照護機構、急性後期照護以及居家模式為主的十年長照計畫，但是這些多樣性的服務更突顯了推動整合照護的必要性，整合照護推動的基礎是無縫的個案管理，目標是讓具有多重且複雜照護需求的長者能在這些服務模式當中平順的接受服務，讓服務本身無縫接軌且發揮完整的效能。在這樣的過程中，整合的過程首重服務本體的整合，而不是急於將部門與機構進行合併，唯有第一線工作者能充分的理解並且有效推動，整合照護的主體才能被彰顯，此時順應需求而進行部門與機構整合才能事半功倍。

The percentage of people aged 65 years and older is estimated to exceed 20% of the total population in Taiwan, which makes Taiwan a ＂super-aged＂ country. This rapid demographic transition, unprecedented in human history, presents unique challenges. The health characteristics of older people differ fundamentally from their younger adult peers, especially in terms of the critical impact of disability on health. Therefore, special attention to the interrelationship between multimorbidity and disability is required in order to provide healthcare services that are appropriate and effective. The integrated care approach of Europe, which concurrently addresses the needs of health and social care, has become the important foundation of social security in the European Union. The healthcare services available to older people in Taiwan, including outpatient, inpatient and intermediate care, are far from satisfactory and extensively fragmented. For older people with multimorbidities and / or disabilities, these fragmented healthcare services result in inconvenient access to healthcare and impaired quality of care and quality of life. At present, Taiwan has developed various healthcare models such as integrated outpatient services, age-friendly healthcare facilities, post-acute care, and a 10-year long-term care program. However, the development of these healthcare models clearly demonstrates the need for service integration. Integrated care promotes seamless case management, which aims to provide smooth access for older people with multiple, complex care needs to essential services and comprehensive healthcare benefits. During the process, the integration of services per se should be prioritized over the prompt merging of departments or facilities. The development and success of integrated care depend on the complete understanding of and promotion by the frontline working staff.