個別化服務計畫對身心障礙者個案管理服務的成效分析～以某市為例

A Study on the Effectiveness of Individualized Service Plans for Case Management Services for People with Disabilities: Taking a Certain City as an Example

本研究旨在探討個別化服務計畫（ISP）在身心障礙者個案管理服務中心（簡稱身障個管中心）的執行成效，研究者從身障個管中心社會工作者如何進行服務評估、擬定ISP、執行情形與服務成效檢視。研究者透過焦點團體訪談及個案記錄文本分析等方式，搜集11工作人員對ISP之理念、如何進行服務評估、擬定ISP、執行情形與服務成效；並對應個案記錄文本，研究團隊試圖從文本試擬定ISP，以多元檢測方式進行檢視。研究發現有五點：第一為身障個管中心之工作者雖皆認同ISP理念，但實際執行資源的評估表單與服務過程記錄呈現不一致的現況；第二，在學習擬定及執行ISP的養成訓練中乃經由模仿而來；第三，服務歷程中若有新議題產生，會試著調整ISP計畫目標並執行；第四，結案前會從歷次ISP檢視目標是否已達成；第五，問題與需求評估較為單一，使得ISP目標亦簡化，雖用心服務但未能滿足實際需求。因此，本研究建議之一為提供適切的教育訓練，包含ISP的理念教育及全面性評估能力，以適切擬定服務目標及盤點可用資源，發展多元服務策略；建議之二，督導機制的發揮刻不容緩，且應該督導者有足夠的能量支持，設立督導諮詢制度及窗口，適時提供督導者各項所需支持，以利服務的有效性。

This study aims to explore the implementation effectiveness of Individualized Service Plans (ISP) in case management service centers for people with disabilities. The researcher examines how social workers conduct service evaluation, formulate ISP, implement the situation, and review service effectiveness. Through focus group interviews and text analysis of case records, the researchers collected 11 staff members’views on ISP concepts, how to conduct service evaluation, draft ISP, implementation status and service effectiveness. Corresponding to the text of case records, the research team tried to test from the text Develop an ISP and conduct inspections using multiple testing methods. The research found: first, although the workers all agree with the ISP concept, the actual implementation resource evaluation form and the service process record are inconsistent; second, learning to formulate and implement ISP training by imitation; third, if new issues arise during the service process, we will try to adjust the ISP plan goals and implement them; fourth, before closing the case, we will review whether the goals have been achieved from all previous ISPs; fifth, The problems and needs assessment are relatively simple, which simplifies the ISP's goals. Although the service is dedicated, it cannot meet the actual needs. Therefore, one of the recommendations of this study is to provide appropriate education and training, and the second recommendation is to implement and develop a support and supervision mechanism.