居家護理與護理之家照護品質之探討

Quality of Care in Home Care and in Nursing Homes

背景及目的：台灣需要醫療照護但不需住院之失能者，能選擇居家式或機構式服務且享有全民健保醫療費用補助。本研究目的在探討居家護理與護理之家服務使用者照護品質差異。方法：利用健保資料庫2005年承保抽樣歸人檔100萬人，擷取2006年門住診就醫申報資料，以1241位居家護理及323位護理之家服務使用者為研究對象。而探討之長期照護品質指標包括跌倒、壓瘡、泌尿道感染、憂鬱、疼痛等等9項。結果：護理之家服務使用者較居家護理服務使用者第一年憂鬱(p<0.001)及第二年泌尿道感染比率高(p=0.001)。利用多變量邏輯式回歸模型，控制其他變項後，相較於居家護理服務使用者，護理之家服務使用者在第一年憂鬱的勝算比為2.62(95％ CI=1.41-3.63, p=0.001)；第二年泌尿道感染的勝算比為1.54 (95％ CI=1.13-2.11,p=.007)。結論：醫療轉介單位、服務提供者應對選擇接受護理之家或居家護理服務者規劃優先且適當之衛生指導，另進行品質管理及照護過程改善，以提供長期照護者更優質之照護品質。

Background and objective: In Taiwan, disabled people who require medical treatment but do not require hospital stays can choose either home or institutional care while still enjoying financial assistance from the National Health Insurance (NHI). Understanding the differences in quality between these two types of long-term care services should increase the quality of care. This study investigated differences in the quality of care received by users of home care and nursing homes. Methods: This study obtained data on 2006 inpatient and outpatient medical claims from the data of one million people in the 2005 National Health Insurance Database. A total of 1241 nursing home residents and 323 home care service recipients were identified. The quality indicators for long term care included falls, pressure ulcers, urinary tract infections, weight loss, depression, dehydration, pain, disorders of sleep and fecal impaction. Results: During the first year, users of nursing homes had higher rates of depression when compared to users of home care services (9.6%vs 4.5%,p<.001). The rate of urinary tract infections among users of nursing homes was greater in the second year (62.1%vs 49.8%, p=.001). After controlling for factors such as age, gender, and injury, the first-year depression rate for nursing home users was 2.62 times greater than that of users of home care services (95%CI：1.41-3.63, p=.001), and the second-year urinary tract infection rate for nursing home users was 1.54 times greater than that of users of home care services (95%CI：1.13-2.11, p=.007). Conclusions: Medical referral units and providers of services should establish suitable guidelines for nursing homes and providers of home care. Quality management and improvements in the health care process should then provide people receiving long-term care with higher quality service.