建立高齡榮民病人轉銜服務照護模式之成效分析

Establishing an Effective Care Model of Transition Services for Elderly Veterans Patients

本研究目的在探討高齡榮民病人執行轉銜服務之成效，研究採準實驗設計於台北某醫學中心選取170位住院榮民病人，以立意取樣法收集實驗組86位、對照組84位個案。實驗組住院期間由轉銜個案管理師每日進行探訪，並於出院後至榮家進行六次探訪，研究過程由轉銜個管師與醫療小組共同討論訂定個案照護計畫，出院時更聯繫榮家保健組醫護人員提供持續性之照護。對照組由病房兼任之個案管理師提供照護服務。研究工具包括憂鬱、日常生活活動功能及轉銜服務滿意度量表，由轉銜個管師收集出院後3天內非計畫再入急診率、14天、30天、90天、180天非計畫性再入院率。結果顯示病人憂鬱程度在出院後第二個月明顯改善(p=.03)，滿意度在出院後第一個月顯著上升(p=.04)，日常生活活動功能及非計劃性再住院率雖無顯著差異(p>.05)，而日常生活功能得分實驗組高於對照組且再住院之百分比亦低於對照組，顯示建立轉銜服務照護之整合性醫療，除可改善憂鬱程度提高滿意度外，對於提升日常生活活動功能及降低再入院率亦有助益。

The purpose of this study was to evaluate the effectiveness of transition services for elderly veterans patients. This study was a quasi-experimental design. Elderly veterans inpatients were selected from a medical center in Taipei . This study randomly assigned patients to experimental group (n=86) or control group (n=84) by convenience sampling. The experimental group received transition services; case managers visited these patients daily. After patients were discharged into veterans’ home, the case managers also visited them 6 times. The health care plan was set up by managers and the medical team of these patients. Upon discharge, the case managers contacted the medical team in the veterans’ home to achieve sustainable health care. The control group received health care from the ward's case manager. The instrument included Geriatric Depression Scale (GDS), Barthel Index Scale (BIS), and service satisfaction. Demographic data were collected by the transition case manager. The unplanned reentry emergency rate, within 3-day, and 14, 30, 90, 180- day unplanned readmission rate after discharged were also collected. The service satisfactions of two groups were signifi cantly different (t=4.20, p=.000). The study showed the patients’ depression level had improved signifi cantly (p = .03) at the second month after discharge and the satisfaction had increased significantly (p = .04) at the first month after discharge in the experimental group. Although there was no significant difference for BIS and unscheduled re-admission (p>.05), the score of BIS in experimental group was higher than the one in the control group. Moreover, the percentage of re-hospitalization in the experimental group was lower than the one in the control group. As those mentioned above, the establishment of a model of transition services not only improved depression level and elevated satisfaction, it also increased patients’ daily activity and showed benefi t in decreasing rehospitalization.