從醫院到社區的四種照顧轉銜模式觀察與討論：以台灣某縣長期照顧管理中心為例

An observation and discussion of four care transfer models from hospital to community: an example of a county government long-term care management center in Taiwan

目標：本研究觀察台灣某縣長期照顧管理中心為因應從醫院到社區的服務轉銜，而逐步嘗試的四種轉銜服務模式。希望藉由訪談參與其中的照顧管理專員，檢視並分析其發展歷程的問題。方法：本研究將X縣的轉銜服務發展歸納、區分為四種轉銜模式，以質性研究訪談方式，立意取樣訪談六位歷經不同階段的照顧管理專員，探究模式發展歷程中的問題。結果：本研究將X縣的發展歷程區分為傳統模式、照專入院、駐院照專與準照專模式。結果發現，傳統模式與準照專模式相對具有轉銜服務效益，但四種模式皆無法單獨因應家屬照顧安排決策過程的多變性。同時，醫院、服務提供單位與照管中心間仍缺乏足夠的溝通與協調。結論：政策的規劃與執行宜更加重視使用者的立場與需求，同時也應持續強化不同服務單位間的溝通與協調，同時中央政府或可多增加跨縣市的經驗交流並提供必要的實務指引、支持或財務支援。 Objectives: This paper reports on four transfer service models trialed by a long-term care management center run by a county in Taiwan. These models were developed to transfer care services from the hospital to the community. Reviews and analyses from the care managers were obtained during the development of the models. Methods: The transfer services of X county were classified into four models. To identify problems in the model development process, qualitative research methods and purposive sampling were employed to analyze data obtained from six care managers who experienced various stages of development process. Results: The development stages of X county's transfer service can be classified as the traditional model, visit care manager model, resident care manager model, and the quasi-care management manager models. The traditional and license-specific models are relatively service-effective. However, the four transfer models cannot manage the variability of the family carer's decision-making process, and communication and coordination between the hospitals, service providers, and long-term care manager center are inadequate. Conclusions: Policy planning and practice should focus on the position and requirements of users and continue to strengthen communication and coordination between different service units. The central government can also simultaneously increase information exchange among local governments and provide the required practical guidance and financial support.