提升病房護理師應用個案管理於出院準備執行率

Enhance Ward Nurses' Implementation of Case Management in Discharge Planning

本院僅配置2位院際出院準備個管師無法掌握全院出院準備執行概況，因病人延遲出院及家屬滿意度低、出院準備收案率低引發書寫專案之動機。本專案目的係應用個案管理模式，提升病房護理師之出院準備執行率。分析導因為護理師出院準備認知不足及缺乏連續性在職教育、未確實執行初篩及不熟悉篩選及評估流程、缺乏出院準備標準手冊。專案小組擬定對策為：設立單位種子人員及區分工作職責、辦理在職教育及遊戲式教學課程；修訂篩選作業流程及工作手冊、制訂出院準備篩選共通表單。專案實施後出院準備概念與認知平均分數由53.4上升至85.3分；出院準備服務執行率由10.5%增加至18.5%，達專案目標。專案實施後可提早規劃病人出院準備、機構安置及長照資源轉銜，醫院政策支持及團隊合作為成功關鍵，執行經驗可提供其他醫療院所參考。

Due to the limited staffing of only two inter-hospital discharge planning case managers, it has been challenging to oversee the overall discharge planning across the hospital. This has led to delayed patient discharges, low family satisfaction, and low case referral rates, motivating the development of this project. The project aims to enhance ward nurses' implementation rate of discharge planning by applying the case management model. The root causes include insufficient nurse awareness of discharge planning, lack of continuous in-service education, failure to perform initial screening effectively, unfamiliarity with screening and assessment processes, and the absence of a standardized discharge planning manual. The project team devised the following strategies: establishing unit seed personnel and delineating job responsibilities, conducting in-service education and gamebased teaching courses, revising the screening process and work manual, and developing a standardized discharge planning screening form. After the project implementation, the average score for understanding and awareness of discharge planning increased from 53.4 to 85.3, and the discharge planning execution rate rose from 10.5% to 18.5%, achieving the project goals. The success of this project has allowed for earlier discharge planning, institutional placement, and long-term care resource transition. Key factors in the success included hospital policy support and team collaboration. The experience gained from this project can serve as a reference for other healthcare institutions.