日本在宅醫療發展對我國居家醫療的啟示

The Development of Japanese Home Medical Care: Lessons for Taiwan

隨人口結構高齡化，失能人口增長，居家照護的重要性逐漸增加。鄰國日本結合醫療與長照的居家照護，稱之為「在宅醫療」。目前日本全國有近1萬3千家在宅療養支援診療所，提供社區民眾居家醫療服務，有365天24小時提供緊急往診和定期居家訪視服務，以團隊照護方式，協調醫療和長照多專業人員，滿足在宅個案的需要。日本在宅醫療的核心價值，是要支持病患在家療養，生活到臨終為止，具有高度的可近性(accessibility) 和可靠性(accountability)，終極目標就是社區安寧療護。「在宅醫療」服務提供者有多專業的人員，來自基層診所醫師、護理師、居家護理所護理師、居家營養師、居家復健師、社工師等其他專業人員，顯示其服務周全性(comprehensiveness)。此外，在宅醫療的服務有高度協調性(coordination) 和照護連續性(continuity)，居家團隊介入協調個案入院以及參與出院的準備。照護對象涵蓋輕度失能、失智到末期患者，因此，臨終照護也是日本在宅醫療品質的重要指標。日本在宅醫療的運作是以病患的「家」為中心的照護體系，可以說完全以家庭醫學的核心價值的2A3C在進行。2000年日本長期照護保險開始給付在宅醫療之後，促使日本在宅醫療相關服務加速發展。然而，各地的發展型態大不相同，例如：長野農村醫學模式，長崎連攜協力模式，和靜岡雙主治醫模式。此外，不同型態診所也大不相同，在宅醫療支援診所類型又分為專門診、混合型與門診優先型（多數）。診所執業型態又可分為一人診所、多人診所。診所規模又可分為自有病床的診所、老人機構合作的診所。2006年日本政府對在宅醫療給付提高後，由地方診所組織的全國在宅療養支援診療所連絡會，形成具政策影響力的專業團體，加速推動日本在宅醫療發展。日本在宅醫療成功的關鍵，在於不同專業人員之間的集體合作，提供社區高效率的團隊醫療服務，因此，基層醫師的參與便顯得重要。此外，相對應保險制度與法規及專業人才的培養也是重要因素。日本在宅醫療發展經驗及因地制宜的運作型態，值得我們學習和深入探討，作為發展台灣在宅醫療支援體系之參考。

The importance of home care has been on a constant rise with the increase in the population of elderly people and that of people with disabilities in virtually every country worldwide. In Japan, medical care and long-term care have been integrated into Zaitakuiryou, a.k.a. home medical care, that serves as an essential part in the country’s home care delivery system. There are currently about 13,000 clinics providing home medical care in Japan through regular and emergent home visits on a 24/7/365 basis, dedicating themselves to meeting the patients’ needs at home with the coordinated teamwork of medical and long-term care professionals. Known for its admirable accessibility and accountability, home medical care in Japan embraces its core value of building a friendly, supportive environment for patients at home and makes home hospice its utlimate goal. Home medical care is highly comprehensive as it is provided by an interdisciplinary team incorporating primary care physicians, nurses, homecare specialists, nutritionists, physical and occupational therapists, social workers and other allied professionals. In addition to comprehensiveness, home medical care is characterized by coordination and continuity with the interdisciplinary team offering assistance during the entire process from hospital admission to discharge for patients suffering a wide range of health problems, ranging from light disability, demntia to terminal illnesses. End-of-life care is accordingly regarded as major index for the quality of the Japanese home-centered medical care, a system based on and working in compliance with the 2A3C core values of family medicine (accessibility, accountability, comprehensiveness, continuity, and coordination). Its inclusion in the long-term care insurance system implemented by the Japanese government in 2000 has triggered the vigorous development of home medical care in Japan. The model of practicing home medical care, however, differs from region to region. There are, for excample, the Nagano rural model, the Nagasaki cooperate model, and the Shizuoka double-physician model. Differences can also be noted in the types of supporting clinics; some specializes in home care exclusively, some provides home care in conjunction with other medical services, and still some are primarily outpatient-based. In terms of size, supporting clinics may also be divided into one- and multiple-physician clinics, clinics working with or without elderly care institutions, and clinics equipped with or without beds. In 2006, these clinics were united as an association named "Home Cares Net," which has since been working with great vitality to advocate and monitor related policies and to accelerate the development of home medical care in Japan. Interdisciplinary collaboration capable of providing community dwellers with high-efficiency, team-based medical services is generally believed to be the key to the success of home medical care in Japan, and the active participation of primary care physicians plays a crucial role in the interdisciplinary collaboration. Also of critical importance, however, is the ongoing improvement of the long-term care system which requires fiscal support from corresponding insurance programs, introduction and amendment of related laws and regulations, and the trainning and fostering of new-generation professionals. To develop a Taiwanese home medical care system, the Japanese experience is definitely worth studying and emulating.