運用整合性照護之彩虹模型分析以強化居家醫療照護

Use the Rainbow Model Analysis of Integrated Care to Strengthen Home Medical Care

目的：因應高齡化人口，全民健康保險居家醫療照護整合計畫自2015年試辦推展至今，政策推動與計畫修正滾動性微調，以達有效接軌醫療照護，降低居家醫療個案再入院之目標效益，本文以第一線工作人員視角，從參與推動的居家醫療過程，以整合性照護彩虹模型分析居家醫療照顧推展困境，以期強化居家醫療照護。方法：藉由整合性照護彩虹模型六大面向，以人為本、以人群為中心探究現行居家醫療照顧推展困境。結果：經整合性照護彩虹模型探究發現照護困境，包括：缺乏全人視角評估、未即時啟動出院準備、溝通文化未完善、資訊和通訊技術使用受限，無共享病歷平台、缺乏獎勵制度、缺乏持續與完整教育訓練、僵化就醫習慣。結論：建議住院期間舉辦跨領域團隊家庭共識會議、建立到院訪視與雙主治照護模式、即時啟動出院準備轉銜服務、建置有效性溝通平台等，並自政策面限制個案或家屬多重院所的就醫與用藥行為，以期無縫接軌提供優質照護，進而達到群眾健康與降低醫療耗用。

Objective: In response to the aging population, since the Home Medical Care Integration Program of National Health Insurance was launched as a pilot project in 2015, to achieve the goal benefit of effectively integrating medical care at home and reducing re-admission of individual cases, this paper analyzed the dilemma of home medical care from the perspective of front-line staff, who participated in promoting the process by using an integrated rainbow model, in order to strengthen home medical care. Method: Through the six aspects of the integrated rainbow model, with the focus on people and the population, this paper explored the current difficulties in the promotion of home medical care. Result: From the study, as demonstrated by the integrated rainbow model, it was found that difficulties included: lack of omniscient perspective evaluation, failure to the immediate start of discharge preparation, incomplete communication, limited use of information and communication technology, lack of shared medical record platform, lack of reward system, lack of continuous and comprehensive education and training, and a rigid habit of seeking medical treatment.Conclusion: It is suggested that a crossdisciplinary family consensus meeting should be held during hospitalization, a hospital visiting and double attending physician care system should be established, a discharge preparation with proper transfer service should be started immediately, and an effective communication platform should be established. In addition, in terms of the policy, the medical treatment and medication behavior of individual cases or family members in multiple institutions should be restricted, to provide seamless and high-quality care; thus, achieving a certain level of public health and reducing wasting of medical resources.