社區整體照顧服務體系之運作與展望：以南投縣為例

The Operation and Prospects of the Community Integrated Care Service System: A Case Study of Nantou County

社區整體照顧服務體系屬於長照2.0之創新計畫，從2017年正式施行以來，其運作模式與實施策略迭經調整與修正，而照顧管理模式之運作以及公私協力夥伴關係之建立，實攸關社區整體照顧服務體系之實施成效，值得深入檢視與探究。循此，本研究以南投縣為研究場域，運用深度訪談法，針對照管中心專員、網絡單位個管員或負責人進行資料蒐集與歸納分析。研究結果顯示，照顧管理層面正面臨權責不明、效率不彰、跨專業團隊合作與長照資源不足等困境；再者，長照政策修正頻繁、民間決策參與不足、行政體系長期分立、培力角色未能彰顯等影響因素，公私協力夥伴關係亦面臨鬆動與解組的挑戰。文後則分別針對照顧管理與夥伴關係層面，提出以照管中心作為單一窗口，建構全責、全程的照顧管理模式，以及建立決策參與及溝通對話機制，強化政府行政效率與培力角色，藉以形塑公私部門平等、尊重與信任之夥伴關係等建議。

The Community Integrated Care Service System is an innovative program under the Ten-Year Long-Term Care Plan 2.0, which aims to establish a community-based integrated service delivery model. Since its official implementation in 2017, its operation model and implementation strategy have been adjusted and revised. The operation of care management and the establishment of public-private partnerships are closely related to the implementation of the community’s integrated care service system, which is worthy of in-depth review and exploration. This study takes Nantou County as the main research field, using in-depth interviews with care managers of the long-term care management center and case managers or leaders of private organizations to collect data. The research results show that at the care management level, there are difficulties such as unclear authority and responsibility allocations, inefficiency, lack inter-professional teamwork and insufficient longterm care resources. In addition, the government’s long-term care policy is still changing, private sector’s role in decision-making is minimal, the administrative system have long been alienated from each other, and the role of empowerment is not obvious. The public-private partnerships are facing the challenge of loosening and disintegration. At the end of this article, several suggestions are made on care management and partnership, including care management center as the only contact, enhancement of related knowledge about inter-professional teamwork, building a long-term care resource network, and establishment of a mechanism of decisionmaking involvement and communications/dialogues, so as to integrate the divided long-term care administrative system, strengthen the government’s administrative efficiency and role of empowerment, and shape the publicprivate partnership that is equal, respectful and trusting.