高價值居家醫療整合照護──臺北市立聯合醫院的經驗與願景

High Value Home Healthcare System--Experience from Taipei City Hospital

因應人口老化，為了整合並提升因失能或疾病特性外出就醫不便病患的醫療照護，政府於2016年正式推出「居家醫療整合照護計畫」，由整合性照護團隊提供「居家醫療」、「重度居家醫療」及「安寧療護」三階段的居家照護。臺北市立聯合醫院執行並升級此計畫，展開藍鵲計畫，由醫師、護理師、藥師、營養師等跨專業組成的藍鵲團隊，踏出醫院進入社區和病人家中，提供「以價值為導向的居家醫療」，自2016年推行至2017年底，藍鵲計畫總共收案過2884個家庭，居家訪視總數達到21987人次，藍鵲計畫包含五大要素，分別是「從生到死的陪伴」、「溝通文化的建立」、「無縫接軌的服務」、「跨團隊的協同照護」及「未雨綢繆的預防醫學」。臺北市立聯合醫院亦期望結合國際最新的P4醫學的精神，做到預防受苦，推動健康促進式的安寧緩和照護，期待建構一個支持性的環境，將臺北打造成具同理心的城市，在此城市內，「在地老化」和「在宅善終」將不是夢想，而是實踐。 To promote the healthcare for the disabled elderly in this aging society, the government in Taiwan initiated the ''Combined Home Healthcare Project'' since 2016, in which a medical team provides three stages of care, from ''home healthcare'', ''severe home healthcare'' to ''home hospice care''. Taipei City Hospital executed and upgraded this project and started the ''The Home Health Care Project of Blue Magpie''. The multidisciplinary medical teams from Taipei City Hospital composed of physicians, nurses, pharmacists, therapists and other specialists walked out of the hospital and provides high value home healthcare at patients’ home in the community. Since 2016, Taipei City Hospital has cared for 2884 families and has provided 21987 home visits in less than 2 years. There are five key essentials in Taipei City Hospital’s home healthcare systems: ''Accompany from life to death'', ''Culture of communication'', ''Continuous service'', ''Coordinated teamwork'' and ''Preventive medicine''. Taipei City Hospital envisions to integrate ''P4 medicine'' in this care system and to push forward the work of ''Health-promoting palliative care'' in the community. Taipei City Hospital aims to transformed Taipei City to a compassionate city, in which ''aging in place'' and ''dying at home'' will become a reality.

To promote the healthcare for the disabled elderly in this aging society, the government in Taiwan initiated the ''Combined Home Healthcare Project'' since 2016, in which a medical team provides three stages of care, from ''home healthcare'', ''severe home healthcare'' to ''home hospice care''. Taipei City Hospital executed and upgraded this project and started the ''The Home Health Care Project of Blue Magpie''. The multidisciplinary medical teams from Taipei City Hospital composed of physicians, nurses, pharmacists, therapists and other specialists walked out of the hospital and provides high value home healthcare at patients’ home in the community. Since 2016, Taipei City Hospital has cared for 2884 families and has provided 21987 home visits in less than 2 years. There are five key essentials in Taipei City Hospital’s home healthcare systems: ''Accompany from life to death'', ''Culture of communication'', ''Continuous service'', ''Coordinated teamwork'' and ''Preventive medicine''. Taipei City Hospital envisions to integrate ''P4 medicine'' in this care system and to push forward the work of ''Health-promoting palliative care'' in the community. Taipei City Hospital aims to transformed Taipei City to a compassionate city, in which ''aging in place'' and ''dying at home'' will become a reality.