超高齡社會下的居家醫療與在宅急症發展之臨床實證與政策建言

Clinical Evidence and Policy Propositions of Advancing Home-Based Medical Care and Acute Care at Home in a Super-Aged Society

隨著我國進入超高齡社會，居家場域醫療照護需求日益攀升。因此健保署陸續開辦提供連續性照護的「居家醫療照護整合計畫」（居整計畫），以及提供急性感染症治療的「在宅急症照護計畫」。居家醫療已知可降低住院率、急診使用率與醫療照護耗用，但服務量能仍待擴充。建議可將「居整計畫」納入「家庭醫師整合性照護計畫」及「地區醫院全人全社區照護計畫」之必要執行項目，並發展遠距與實體結合的混合照護模式，以提高居家醫療可近性與服務效率，同時應讓高風險族群能優先獲得服務。現行「論量計酬」模式不易支持以病人為中心的團隊照護，建議朝向「價值導向支付」調整，鼓勵團隊提升照護品質。「居家住院」可分為「早期出院支持」與「避免住院」兩大模式。根據國際調查顯示，多數收案來源為住院病房，反觀我國目前給付的模式為「避免住院」。建議可發展「早期出院支持」模式，讓穩定病人提前回家治療，優化急性病房資源之運用。此外，緩和醫療與「居家住院」概念可以結合，予以安寧居家療護提供密集照護的彈性，提升末期病人症狀控制與照護品質。未來應透過政策持續修正，以強化「居整計畫」與「在宅急症」服務，確保病人獲得適切且高效的居家場域醫療照護。

As the population ages and the number of individuals with disabilities increases, the demand for homebased medicine continues to rise. Therefore, the National Health Insurance Administration has successively launched the“Integrated Home-Based Medical Care”(iHBMC) to provide continuous care, as well as the“Acute Care at Home”(ACAH) to deliver treatment for acute infections. Home-based medical care is known to reduce hospitalizations, emergency department visits, and overall healthcare utilization, yet service capacity remains insufficient. It is recommended that the iHBMC be incorporated as a required component within the“Family Practice Integrated Care Project”and the“Comprehensive Community Care Program for District Hospitals”. A hybrid model combining telemedicine and in-person visit should be developed to improve access and efficiency, while prioritizing services for high-risk populations. The current fee-for-service model inadequately supports patient-centered, team-based care; a shift toward value-based payment is needed to incentivize quality.“Hospital at Home”(HAH) can be categorized into two main types:“Early Supported Discharge”(ESD) and“Admission Avoidance”(AA). International data show that most HAH cases originate from inpatient wards, while Taiwan’s current reimbursement model primarily supports admission avoidance. Developing ESD could enable stable patients to return home earlier and optimize acute inpatient care capacity. Furthermore, integrating HAH with palliative care by increasing flexibility for intensive home visits can enhance symptom control and the quality of end-of-life care. Ongoing policy reform is essential to strengthen both the iHBMC and ACAH Program, ensuring patients receive appropriate and effective home-based medical care.