長期照護資源整合服務之推廣經驗——以臺北市立聯合醫院為例

The Promotion of Resources Integration in Long-Term Care Service: The Experience of Taipei City Hospital

臺灣全民健康保險居家醫療照護整合政策的推動，從原來健保給付的居家醫療、居家護理、居家呼吸治療及安寧照護，整合提供一條龍的延續性居家醫療照護服務。以往居家護理侷限於在醫師訪視規範下執行醫療相關評估，對行動不便或就醫困難的民眾幫助有限。自2016年開始擴充醫師執業場域，鼓勵醫師走出白色巨塔，同時也為民眾提供更多元的就醫選擇，期能改善病人的就醫習慣。以家為概念的醫療服務體系，深根社區，以建立完善的社區式醫療照護整合模式，透過出院準備服務與銜接團隊接軌，在出院前即時與銜接團隊進行相關交班及持續性的照護服務，更是重要課題，期能成為全球無縫接軌的居家醫療照護整合服務模式，不僅銜接後續的健康識能、復健、居家醫療、居家護理、社區安寧、死亡照護等服務，同時整合社區資源，建構社區資源網絡，提供更高品質的社區照護服務。

The home-based medical care integrated plan under Taiwan National Health Insurance has changed from paying for home-based medical care, home-based nursing, home-based respiratory treatment, and palliative care to paying for a single, continuous home-based care service package. Formerly, physician-visit regulations limited home visits for home-based nursing to providing medical related assessments only. This limitation not only did not provide practical assistance to the public but also caused additional problems for those with mobility problems or who faced difficulties in making visits hospital. This 2016 change in regulations opens the door for doctors to step out their ‘ivory tower', while offering the public more options to seek medical assistance in the hope that patients may change their health-seeking behavior. The home-based concept that underlies the medical service system is rooted deeply in the community in order to set up a sound, integrated model of community medical care. It is a critical issue to proceed with timely job handover confirmation with the connecting team and to provide patients with continuous-care services prior to discharge through the dischargeplanning service and the connection with the connecting team. This is currently believed to be the only continuous home-based medical care integrated service model in the world. This model not only connects services such as health literacy, rehabilitation, home-based medical care, homebased nursing, community palliative care, and death but also integrates community resources, builds community resources networks, and provides high quality community care services.