居家照護與長期照顧2.0的結合

Medical Home Care and National Long-Term Care Integration

依著人口老化，國內外也開始推展在地老化、健康老化等策略，支持社區長期照護體系的建構，以在地服務滿足照顧需求，臺北市於2008年成立長期照護中心來服務失能長者，但因照顧管理專員不足，長照服務人力及資源不均，平均等待服務時間過長等缺點，於是臺北市規劃了社區整合照護模式來因應高齡社會的長者照護需求。2016年7月社會局推動「石頭湯計畫-社區整合照顧服務」，委託聯合醫院承接蘭州國宅為服務場域，結合衛政、民政、社政加民間資源，以居家醫療服務為領航，結合跨專業領域共同訪視。建立生活管理師制度，評估長者需求並聯結資源，以地利之便提供更快速的服務，深入了解長者生活核心，和家屬共同從生到死的生活照顧，讓長者能在家安養。

According to the aging population, Taiwan and other countries also began to promote the aging in place and healthy aging strategies, supporting the establishment of long-term care system in the community to meet the needs of care locally. The Taipei City had established a long-term care center in 2008 to serve the disabled elderly. However, because of the shortage of the caring management officers and long-term care service manpower, uneven resources, and long average waiting time for the service, Taipei City has planned a community integrated care model to meet the needs of the care for the elderly in the aging society. In July 2016, the Department of Social Welfare had promoted the ＂Stone Soup project-Community Integration Care Service＂. Taipei City Hospital was entrusted to undertake the Lanzhou Public Housing as a service field. Combining with health affairs, Civil affairs, social affairs as well as the non-Government Organization resources take the home-based medical service as the first priority, Taipei City Hospital co-visit the patients along with the interdisciplinary teams. With the establishment of a life manager system, the needs of the elderly can be assessed, and the resources can be well organized in order to provide the elderly with a faster service locally. To deeply understand the real life of the elderly, and to take care of the elderly with their families from the beginning till the end; as a result, the elderly can feel more secure and relax at home.