出院準備服務轉銜居家醫療照護整合計畫之經驗分享

Examining Effectiveness of Integration Program for Transition from Discharge Preparation to Home-based Medical Care

本文旨在探討出院準備轉銜居家醫療整合計畫之成效。以北部某區域醫院在2018年3月至2021年12月期間，共轉介居家醫療照護整合計畫341位。統計顯示住院期間有召開出院準備跨團隊會議比率為75%，轉介後有使用居家醫療照護整合計畫成功媒合率為83.9%，其出院14天內再入院率為1.2%，其中轉介居家醫療照護整合計畫又同時協助進行長照友善醫院評估者共有35人(10.3%)，以重度居家醫療個案最多有33人(9.7%)，透過出院準備服務小組召開跨團隊會議，進行資源整合及轉介，提供居家醫療照護服務或長照評估等相關資源讓病人在返回社區後不同階段的病程中，對於失能、不便行動者仍能夠持續得到醫療照護，持續提供以病人為中心之居家醫療照護整合計畫。

 

The purpose of this study was to investigate the effectiveness of the integration program for transition from discharge preparation to home-based medical care. A total of 341 referrals to home-based medical care services were recommended based on the integration program at a regional hospital in northern Taiwan from March 2018 to December 2021. Statistics showed that the rate of holding transdisciplinary meetings for discharge preparation during hospitalization was 75%. The rate of successful referrals was 83.9%, and the rate of readmission within 14 days was 1.2%. 35 (10.3%) of the patients agreeing to the referral also received long-term care assessment at the hospital, and 33 (9.7%) were recipients of advanced home-based medical care. With the transdisciplinary meetings coordinated by the discharge preparation service team to integrate and refer resources, the patient-centered integration program is capable of helping disabled patients receive needed long-term care assessment and home-based medical care services in the different stages of their illness after returning to the community.