提升病人轉銜長照2.0成效之計畫

The Project to Improve the Transfer Rate of Long-Term Care 2.0

本文旨在探討某醫學中心提升病人轉銜長照2.0服務之成效，本院2019年1-6月協助出院病人轉銜長照2.0僅26.9%，低於同儕平均值，分析原因為：（1）醫療團隊對長照2.0認知不足、（2）病人與家屬對長照提供之服務理解錯誤、（3）缺乏長照指導教材、（4）符合長照個案篩選資訊不實用、（5）收案轉介流程不明確。在院方支持下擴大出院準備專責團隊，舉辦在職教育、製作護理指導單張、設置長照專區、促進跨團隊合作與優化資訊系統篩選潛在收案名單、重新制定轉銜流程及交班單等措施後，轉銜率提升至34.9%，除此，也促成醫療團隊在急性後期照護計畫與分級轉診計畫的重視，在推動專案時發現評估舊案量已開始增加，且評估作業費時，建議未來政府能整合既有的資料庫與醫院系統進行串聯，並評估簡化評估內容，使醫院出院準備專責人員能將更多心力在整合病家對急性後期與長期照護服務的較長遠之規劃，讓病家更能感受到政府推動長照服務政策的美意。

This project aims to assist patients and their families in accessing the long-term care (LTC) system during discharge planning. The transferred rate of LTC of our hospital team is only 26.9% from January to June 2019, which is much lower than the rate of our peers. The causal analysis revealed the followings: (1) medical team was unaware of the LTC 2.0; (2) patients and family members misunderstood the LTC service content; (3) lack of LTC health education materials; (4) ineffectiveness of the current screening tool; and (5) unclear referral process. Therefore, we proposed multiple methods to overcome these issues. First, we expanded our team to propagate information on LTC by holding LTC conferences with the discharge planning committee, holding in-services training for the medical team, designing and producing LTC leaflets, and setting up the LTC information center. Moreover, we established an information system to facilitate the medical teams' communication and cooperation with us and to screen and select the potential candidates systemically. We also refined the referral process and built up the handover and checklists in our teams. As a result, the transferred rate to the LTC 2.0 increased to 34.9%. This article aimed to share our efforts to help more patients. Furthermore, we look forward to establishing an information system link with other database and to improve efficiency of transfer through better planning in the future.