居家醫療服務跨專業連結之困境與挑戰

The Obstacles and Challenges of Providing Transdisciplinary Care in Home-Based Primary Care

因應我國人口快速老化，失能人口日漸增加，健保署於2016年起推動「居家醫療照護整合計畫」。居家醫療病人多有複雜需求，需要多種專業提供照護。多種專業間（Multiple disciplinary）的合作模式，可分類為「多專業」（Multidisciplinary）、「專業間」（Interdisciplinary）和「跨專業」（Transdisciplinary）合作。在居家醫療提供跨專業（Transdisciplinary）照護面臨的問題有，缺乏多種專業（Multiple disciplinary）的資源、各專業分屬不同組織、成員缺乏「跨專業」合作之意識、居家醫療團隊對長照服務的認識不足。欲克服跨專業合作的困境，建議如下方式，採用有效的溝通策略、召開團隊會議、建立溝通資訊平台、醫師意見書計畫與居家醫療互相搭配、訓練課程中加入跨專業的概念、採用遠距諮詢模式、支付制度調整為論價值計酬的模式。各專業成員都必須由”我能提供什麼”的思維，轉變成”病人需要什麼”的思維，才能緊扣住以人為中心的照護原則。

In response to the rapid aging of Taiwan's population and the increasing number of disabled people, the National Health Insurance Administration has launched the ''Integrated Home-Based Primary Care Program'' in 2016. Patients who are homebound have complex needs and require care from multiple professionals. The multiple disciplinary collaboration models can be classified into ''Multidisciplinary,'' ''interdisciplinary,'' and ''Transdisciplinary'' collaboration. The obstacles in the provision of transdisciplinary care in home-based primary care include the lack of multiple disciplinary resources, and each discipline belongs to different organizations, the lack of awareness of the ''transdisciplinary'' concept among staff, and the short of understanding long-term care (LTC) services. We recommend the following methods to overcome the obstacles: effective communication strategies, holding team meetings, establishing an information platform for communication, collaborating between Doctors' opinion papers in LTC needs program and home-based medical care, adding transdisciplinary concepts into training courses, and adopting remote consultation. We should modify the payment system toward a value-based compensation model. All disciplines must change from the thinking of ''what I do'' to the thinking of ''what the patient needs'' to firmly follow the principle of people-centered care.