醫院與慢性病醫療和整合照護

Hospital-based Integrated Care Model for Chronic Diseases

台灣逐漸步入老年社會，多重慢性病患將與時俱增。發展出適合多重慢性病患照護之整合性醫療照護，以提供周全性的照顧，有效率的分配醫療資源，乃當務之急。整合照護是以溝通協調的方式針對醫療、臨床照護、服務、財務、管理與組織模式加以組合。隨著照護目的之不同，所需考慮的管理方式、照護目標、整合方式也大不相同。本文簡介多種不同的照護模式，並針對過去研究歸納出整合照護成功與失敗之因素。並針對醫院進行整合照護提出幾點注意事項。文中提出以醫院為主發展的慢性病照護模式為例，以實際發展的經驗來應證過去成功的因素包括：凝聚各科共識，共同建立整合照護流程；消弭科際間文化差異並提供適當誘因；邀請其他專科加入，擴大照護面；連結社區資源，共同照護慢性病病患。期待建立完善的慢性病整合照護模式及新的照護文化，發揮各專業完成病人的醫療照護需求與價值，成為新時代的醫療體系。 Taiwan has been entering aged society gradually and brought numerous patients with multiple chronic diseases. It is an urgent and priority issue to integrate health care system to provide the comprehensive medical service and allocate the medical resources efficiently. The integrated system have to consider of medical service, financial support, resources management, and care model as well. The different care purpose and goal, the diverse care model, resources allocation and management, and integrated care scheme should be considered. In this article, we will introduce different kind of health care models and discuss the success or failed factors in integrated care service. The chronic disease integrated care model in our hospital was used as an example to illustrate the factors for success, which included consolidating the consensus of each department, establishing an integrated care process, providing appropriate incentives, inviting different specialists to join program, and linking community resources as well. The objective of this study expect to establish a new hospital-based comprehensive integrated care model for chronic diseases patients and build a new care culture to fulfill the professional medical care needs and values for patients.