從醫療實務者角度說明社區整體照護模式A單位執行之整合困境與整合經驗

The integration dilemma and integration experience of the implementation of the overall community care model Unit A, from the perspective of medical practitioners

隨著醫療的進步，我國人口高齡化儼然成為必然趨勢，為了建立以社區為基礎的照顧型社區並實現在地老化的願景，我國於2017年提出長期照顧十年計劃2.0，擴大服務對象及服務項目，以在地老化為方向，期望讓老人家在居家或社區當中就能獲得服務，減少機構化，並以社區整體照顧服務體系ABC做為核心概念，將過去各自發展互無關聯的長照相關服務與社區資源，將其銜接起來，以系統化建立社區整體照顧模式。社區整體照顧A單位委由機構承接，為失能者擬定照顧服務計畫及連結或提供長照服務為主要服務內容，然在服務串聯、專業人員有效利用、個案管理落實、系統整合與應用等皆面臨極大的挑戰。本專案以2019年世界衛生組織提出整合照護（Integrated care for older people, ICOPE）理論做為說明，以醫療機構為A單位執行者，面臨之困難及如何整合專業人才且有效利用其專業為背景，以實務工作者角度，探討分享醫療院所個案管理師，在執行A單位整合服務面臨工作定位困境與如何應用單位優勢達到服務整合與應用模式。

With the advancement of medical care, the aging of the population in Taiwan has become an inevitable trend. In order to build a community-based care model and realize the vision of local aging, our government proposed a long-term care ten-year plan 2.0 in 2017 to expand services. Targets and service items are oriented towards local aging. It is hoped that the elderly will be able to obtain services at home or in the community, reducing institutionalization. It is taken the community's overall care service system＂ABC＂as the core concept, and linked the past development of the unrelated Long-term care resources together to systematically establish an overall community care model. The community care Unit A committee is undertaken by the organization, and the main service content is to formulate care service plans and link or provide long-term care services for the disabled. However, it is in service connection, effective use of professionals, implementation of case management, system integration and application, etc. All face great challenges. This project used the theory of Integrated care for older people (ICOPE) proposed by the World Health Organization in 2019 as an illustration. It takes the medical institution as the executor of Unit A, the difficulties faced and how to integrate professionals and effectively use their profession as a background. From the perspective of practical workers, discuss and share the work positioning difficulties faced by medical institution workers in the implementation of Unit A integrated services and how to apply unit advantages to achieve service integration and application models.