整合跨團隊資源之個案管理照護方案提升癌症病人重返治療率之改善專案

Effects of an Interdisciplinary Care Program on Improving the Return-to-Treatment Rate Among Cancer Patients

背景：癌症病人重返治療是影響病人治療成效之重要因素，也是腫瘤個案管理師服務品質重要指標。分析本院2012年癌症病人重返治療率33.3%較2011年38.5%低，發現問題：一、缺乏提醒及監測機制；二、無明確訂定癌症病人拒絕及中斷治療訪視追蹤流程；三、缺乏在職教育訓練；四、未整合跨團隊照護資源及明訂轉介流程。目的：提升癌症病人重返治療率大於45%。解決方案：增設提醒及監測機制、建置癌症病人拒絕及中斷治療訪視追蹤流程、舉辦在職教育訓練課程、整合跨團隊照護資源及轉介流程。結果：重返治療率顯著提升高至48%。結論：證明腫瘤個案管理師整合跨團隊資源方案，透過增設監測機制、在職教育、及適當轉介，能有效讓病人重返治療。

Background & Problems: The return-to-treatment rate is an important indicator of treatment outcome and care effectiveness in cancer patients. The return-to-treatment rates for patients at National Taiwan University Hospital (NTUH) in 2011 and 2012 were 38.5% and 33.3%, respectively. In order to improve the quality of care that is provided to patients, we reviewed NTUH's current clinical case management protocols for handling patients who refused treatment and then identified and resolved the potential problems in these protocols. Purpose: To raise the return-to-treatment rate above 45% by 2013. Resolution: We developed four new interventions to improve the return-to-treatment rate. Firstly, we assembled a quality care team that monitored the rates of patient return to treatment on a monthly basis and reminded case managers to follow up with patients regularly. Secondly, we introduced new protocols for case managers that facilitated the ongoing analysis of the reasons that patients elect not to return to treatment. Thirdly, we delivered regular education programs for case managers addressing good quality and quantity care for cancer patients. Finally, we developed an interdisciplinary liaison care program for patients. Result: After implementing these four interventions, the return-to-treatment rate improved to 48% in 2013. Conclusion: This improvement project demonstrated that integrating an interdisciplinary team, assembling a quality care team, implementing new protocols to help cancer patients who refuse to commence / continue treatment, providing regular education to clinical case managers, and enacting an interdisciplinary care program were all helpful to improving the effectiveness of cancer care services and the return-to-treatment rate of cancer patients.