地區醫院在PAC照護的角色

The Role of Regional (Community) Hospitals on Post-Acute Care in Taiwan

急性後期照護（Post-Acute Care, PAC），在歐美國家已逐漸發展為急性醫療與長期照護的橋梁，俾使照護流程無縫接軌。美國聯邦醫療保險在PAC之支出，自2000年以來均有成長，但是美國腦中風患者住院天數，由1990年的8.8天減至2000年的5.1天。而30天再住院率大約15.51％，相對於台灣14天再住院率17.4％及一年50％再住院率，台灣實有改善之必要。中央健保署於2014（民103）年開始試辦PAC計劃，由於腦中風乃美國十大PAC需求疾病之一，在台灣，腦中風亦為超長住院之首要疾病，患者一年內51％再住院，故選腦中風為PAC試辦計劃（PAC-CVD）。由於成效頗佳，健保署於2017（民106）年再增加燒燙傷、創傷性神經損傷、脆弱性骨折、心臟衰竭、衰弱高齡病患等五種PAC疾患，針對不同疾病納入多面相的專業人員，定出不同的照顧期間及不同的收案標準。地區醫院由於醫療人員少，行政流程簡便，在PAC中可發揮協同照顧，完成全人照護。另外地區醫院多屬於社區型醫院，病患可以選擇離家近的醫院繼續治療，作為急性醫療的中繼站。員生醫院自2018年承辦PAC計畫，以來收案已有15人，其中11位ADL／IADL進步，1位退步、1位中斷回家、2位因病情轉變無法繼續接受本計畫照顧。PAC不僅紓解醫學中心一床難求的困境，亦使地區醫院病床活絡，對病患、家屬也有喘息與長期照護無縫接軌，達到多贏的目標。 In Europe and the United States, post-acute care (PAC) has gradually developed as a bridge to link acute medical care and long-term care, so that the healthcare process is seamlessly integrated. The payment of the U.S. Medicare for PAC has been growing since 2000, however, the days of hospitalization for stroke patients decreased from 8.8 days in 1990 to 5.1 days in 2000. The 30-day re-hospitalization rate was approximately 15.51% in US, while Taiwan shown higher rate on 14-day re-hospitalization rate with 17.4% and 50% rehospitalization rate for one-year. In Taiwan, stroke is one of the leading diseases of extra-long hospitalization, and at the 51% rate of one-year readmission. Hence, Taiwan National Health Insurance Administration has been selecting stroke as the PAC pilot program (PAC-CVD) from 2014. Moreover, in 2017, Taiwan National Health Insurance (NHI) Administration has decided to include burn injury, traumatic nerve injury, fracture, heart failure and debilitated elderly patients into PAC program owing to PAC-CVS’s good outcome. Regional (community) hospitals has the privileges on efficient horizontal integration among departments in hospital and close collaborations with communities nearby, thus it’s more feasible and accessible for community hospitals to carry on PAC as a mid-way between acute care and community care. In this article, the PAC in Yuan-Sheng Community Hospital in 2018 has shown a good outcome between enrollment and discharge from PAC program, the MRS improved from 3.8 to 2.5 and Barthel scale Index increased from 52.3 to 84.3 as well. In conclusion, PAC provides not only a seamless care with good results for patients, but also reduce crowded and promote utilization of acute care units.