無縫接軌長期照顧-出院準備服務護理師之角色功能

The Role and Functions of Discharge Planning Nurses in the Transition to Long-Term Care

台灣正快速邁向超高齡社會，長期照顧需求急遽增加，同時家庭照顧功能卻日漸式微。在這樣的社會背景下出院準備服務在確保病人從醫院順利轉銜至社區或家庭照護中扮演著關鍵角色。本文透過文獻回顧，探討出院準備服務之定義、出院準備服務護理師角色功能、及出院準備服務的發展與挑戰。結果顯示，出院準備服務護理師的角色功能包括照顧與評估者、溝通協調者、資源連結者與個案管理者，特別是在複雜疾病個案管理上更能發揮其獨特優勢。然而，臨床實務中仍面臨諸多挑戰，例如個案出院時間難以掌握、個案與家屬對長期照顧資源選擇意願反覆、各地方政策差異、及人力資源有限等。為了有效應對高齡社會的長期照顧需求與紓解家屬與社會照護負擔，建議持續強化出院準備服務護理師在出院準備服務中的多元角色功能，尤其是溝通協調、資源連結及個案管理方面，以確保出院準備服務的品質，實現長期照顧政策目標。

Taiwan is rapidly approaching a super-aged society, with a sharp increase in long-term care needs, while family caregiving functions are gradually declining. Against this social backdrop, discharge planning services play a crucial role in ensuring patients' smooth transition from hospitals to community or home care. This paper, through a literature review, explores the definition and development of discharge planning services, the roles and functions of discharge planning nurses, and the development and challenges of discharge planning services. The results show that the roles and functions of discharge planning nurses primarily include care assessor, communication coordinator, resource linker, and case manager, with particular advantages in managing complex disease cases. However, clinical practice still faces numerous challenges, such as difficulties in determining discharge timing, fluctuating willingness to choose long-term care resources, differences in local policies, and limited human resources. To effectively respond to the long-term care needs of an aging society and alleviate the burden on families and social care, it is recommended to continuously strengthen the diverse roles and functions of nurses in discharge planning services, especially in communication coordination, resource linking, and case management, to ensure the quality of discharge planning services and achieve long-term care policy goals.