肺癌之整合性照護：以南部某醫學中心為例

Integrated Care for Lung Cancer at a Medical Center in Southern Taiwan

在民國2001年後，肺癌已蟬聯我國十大惡性腫瘤為第一長達至今，不論是罹癌人數、住院天數、醫療支出上都以倍數增加，現今因醫療科技發達、人口平均老化，間接導致罹患肺癌病人生命存活期延長，以傳統醫療體系為主要的醫療照護模式已不再適用，「整合性照護」是以病人為中心，透過多專科醫療團隊成員提供照護及資源連結，最終讓病人、家屬、急性醫療機構與社區，共同構連成一體系，而個案管理師於各期間擔任統合角色，協助團隊成員各司其職。整合性照護特色在於提供病人水平及垂直的兩種照護概念，水平照護是指在同一時期跨科部的醫療照護資源，如：住院期間跨科部照會，垂直照護則是指橫跨時間及地點的縱貫性照護，如：社區醫療輔具轉介。本文將以南部某醫學中心為例，闡述肺癌整合性照護模式各角色工作核心內容、照護模式運用及其成效，並提供建議與流程圖供讀者參考。

Lung cancer has been ranked as the most common type of cancer in Taiwan since 2001,with exponentially growing numbers of cancer patients and length of stays. With the medicalexpense of hospitals increasing at an alarming rate due to the aging of the patient populationand the need for current technology, the traditional health care system is no longer effective.Due to this, integrated care is becoming a crucial part of the health care system. Integratedcare is patient-oriented care provided by an interprofessional transdisciplinary team with thegoal to unite the patient/family, acute care medical institution and the social community asone unit. Case managers play the leading role of the multidisciplinary team to collaboratewith other professionals. There are two types of integrated care: horizontal care which linkssimilar levels of care within a medical facility to incorporate different departments, andvertical care which links different levels of care such as primary, secondary, and tertiary carein multiple facilities. The process and outcomes of integrated care for a lung cancer patient ata medical center in southern Taiwan will be addressed in the following report along with theprocedure and flow chart of the integrated care model.