高齡精準健康照護──Geri-FORCE個管系統

Precision Health Care for Older Adults: The Geri-FORCE Case Management System

高齡者健康問題常是多重共病與老年病症候群交錯，且併有心理社會層面等問題，過去以單一疾病為主的醫療照護模式，恐難適當處理高齡者健康問題。因此，本文從個案管理架構（評估、計畫、執行、協調及評值與互動）出發，結合老年周全性評估、跨專業團隊整合及連續性照護的服務輸送，討論以高齡者為中心的照護模式。為建立高齡精準健康照護系統，台灣高齡照護暨教育協會在國民健康署的計畫下，發展出台灣高齡照護成效及增能模式（geriatrics formulated by outcome related care & empowerment, Geri- FORCE模式），期能將高齡個案管理機制結合Geri-FORCE模式，發展資訊化高齡照護個管系統，能更有效率為高齡者找出主要健康問題，並量身制訂精準且個別化的連續性整合照護計畫， 以提升高齡照護品質，預防及延緩衰弱或失能， 進而減輕醫療與長期照護成本支出。

Health problems in older adults are often concomitant with multiple comorbidities and geriatric syndromes that involve the psychological and social domains. Traditional models of disease care address the health problems of older adults inadequately. Therefore, we applied a case management framework (assess, plan, act, coordinate, evaluate and interact) to discuss how to implement an elderly-centered approach to integrated care that integrates comprehensive, multidisciplinary, and continuous care. The Geriatrics Formulated by Outcome Related Care & Empowerment (Geri-FORCE) was developed by the Formosan Association of Care and Education for the Seniors to help establish a geriatric case management system grounded in precision health care. We propose developing an informatics technology system for older adults that integrates the Geri-FORCE model with case management. This system should accurately identify the main health problems in older adults and provide a care plan that is patient-tailored, integrated, and continuous. We expect that the developed Geri-FORCE case management system will improve quality of care and promote health while reducing care burdens and costs.