慢性病照護模式於HIV感染群體的評估

Assessment of Chronic Care Model in People living with HIV

台灣引入高效能抗愛滋病毒治療法後，使得愛滋病致死率大幅降低，HIV感染群體有別於其他的慢性病，受到社會文化價值、烙印與歧視，影響他們主動就醫與接受訊息，健康照護提供者若能有效建構夥伴關係的照護網絡，應有助於HIV感染群體培養良好的自我管理能力。本文將以「慢性病照護模式」作為HIV感染群體的照護藍圖，其執行內涵須包含：社區政策、自我管理支持元素、健康照護組織、決策支援、傳遞系統設計及臨床資訊系統，關鍵在於盤點社區資源之可近性及群體使用性，藉此提供以實證指引為基礎的醫療決策且將決策的責任和資源控制權授予個案，經臨床資訊系統提供相關的數據，並設有監控通報系統以利追蹤異常，及適當轉介至次專科，透過多專科跨團隊的醫療照護體系，提升「HIV感染」群體良好的照護品質，藉著此六大元素評估，發覺群體的健康照護需求，本文嘗試將此新的轉變模式，作為評估HIV感染群體的另一種選擇。

The introduction of highly effective anti-HIV therapy in Taiwan has greatly reduced the mortality rate of AIDS. Unlike individuals with other chronic diseases, those with HIV are affected by social and cultural values, stigma, and discrimination, preventing them from seeking medical treatment and receiving information. If health care providers effectively construct a partnership care network, this will aid HIV-positive individuals in developing adequate self-management abilities. This paper adopts the chronic care model as the blueprint for the care of HIV-positive group as well as discussed the use and assessment of its six elements and its implementation among people with HIV. To facilitate the referral and use of the chronic illness care program, its implementation should consider community policy, self-management support, health care organization, decision support, delivery system design, and clinical information system. The key measures for successful implementation are checking the accessibility of community resources and making clinical decisions based on empirical guidance while also empowering and encouraging patients to participate in the decision making. To provide relevant information through the clinical information system, an alarm system was set up to track abnormalities and properly refer them to interdisciplinary specialists. Through the interdisciplinary team, the quality of life was improved. Furthermore, assessment of the six elements of the model led to a clearer understanding of the medical needs of people with HIV. This article attempts to use this new transformation model as an alternative for evaluating people with HIV.