醫院與居家醫療照護整合計劃――嘉基經驗

Experience of integrated hospital and home-based medical care from Chiayi Christian Hospital

為了解決與日俱增病患就醫不便問題及社區醫療需求性的增加，居家醫療的必要性因此而生。居家醫療核心價值，係支持病患在家生活為目標，故從療養、生活到臨終，能夠減少不必要出入院與醫療。良好的居家醫療服務模式需有高度協調性及服務連續性，不僅橫跨長照服務與醫療服務的專業範疇，亦必須連結基層診所醫師於在地發揮其功能。然而在居家醫療的發展中，許多問題亟待克服。我們希望除了在保險給付制度更健全外，也能發展出一智慧科技平台，作為各專業照顧溝通及記錄之用。此外，居家長者的營養管理、定期的生活品質調查、山區交通的便利性、各專業溝通能力的提升等，都需要我們一同來努力。本文乃以嘉義基督教醫院從事居家醫療整合照護計畫之經驗與同道分享，特別強調成功關鍵因素為資訊平台、兼顧長者營養及完整的健保給付。 Home-based medical care has been developed due to increase numbers and needs for the frail elders who have difficulties in accessing to medical facilities. The core value of home-based medical care is to support the patients for making themselves independently from the beginning of treatment to hospice care, which also could reduce the overall costs. A good model of homebased medical care consisted of effective coordination and continuity. It’s not only integrate medical care and long-term care, but also out-reaches to primary care clinics. However, there are still challenges to be overwhelmed. First, the health insurance payment scheme for the home-based medical care should be more reasonable. Second, an artificial intelligent platform has to be developed to integrate all information. Furthermore, nutrition management, routine quality of life survey, and convenient transportation for elders as well as increase ability of communication between professionals and home-based medical care patients are all crucial issues. This article shares the experience of integrated home medical care program from Chiayi Christian Hospital, which emphasizes that the integrated information platform, comprehensive elderly nutrition support and reasonable health insurance payment are the key factors to succeed.