基層醫療推動預防失能之慢性病計畫成效探討

Effectiveness of Implementation of Prevention/Delay Disability Health Care Service for Older Patients With Chronic Diseases in the Primary Health-Care Setting in Taiwan

目的：本研究期望建構適合我國基層醫療之老年人照護模式，壓縮長者失能時間，降低醫療照護負擔。

材料與方法：10群社區醫療群針對具三高（高血壓、糖尿病、高血脂）之一高且65歲以上長者進行WHO10分鐘量表篩檢及檢視個案多重用藥問題，診所依照評估結果提供適當介入，並在至少60天後追蹤後續狀態。

結果：12,506位長者平均年齡為74.6±6.9歲，女性占61.9%，29.4%長者為多重慢性病用藥者，評估結果個案有任一項異常的比例為66.7%。其中6,247人經過介入服務60天後再次追蹤評估，整體結果為「改善」有43.44%，「不變」有 25.16%，「惡化」有 9.0%，前後都「正常」則有 22.39% 。

結論：基層診所具有篩檢及發現個案的量能，介入後各指標皆能在短期內獲得改善，而長期預防延緩失能的效果則有待更長時間追蹤。

 

Objective: This study aimed to develop a community health care–based integrated care model for older patients to limit the occurrence of disability in this group and promote healthy aging in Taiwan.

Methods: Ten primary care group practices participated in this study. The primary care doctors and staff were trained to conduct a brief comprehensive assessment and management of older people. Patients eligible for evaluation were those aged ≥65 years with at least one of the following diseases: hypertension, diabetes mellitus, and hyperlipidemia. The assessment included a 10-minute comprehensive screening test, a frailty examination, and a medication review. A care plan was developed based on the results. Patients were followed-up after 60 days.

Results: In total, 12,506 participants were enrolled; their mean age was 74.6 ± 6.9 years, 61.9% were female, and 66.7% had at least one abnormal assessment. After suitable intervention, 6,247 participants were followed-up in 60 days. The data revealed that after ntervention, the condition of 43.4% of the patients improved, 25.16% remained abnormal, and 22.39% remained normal; only 9.0% of the patients experienced a deterioration of their condition.

Conclusions: Our results indicate that comprehensive geriatric assessment and care planning delivered by primary health care providers is effective and practicable.