屏東縣社區護理師高齡友善照護之經驗──以長者健康整合式評估與照護為例

Age-Friendly Health Care: An Example of Providing Integrated Care for Older People (ICOPE) in Pingtung County, Taiwan

高齡化成為21世紀全球普遍的社會趨勢，對醫療照護體系帶來複雜性的挑戰。台灣在2025年即將邁入「超高齡化社會」。2020年國民健康保險署參考世界衛生組織長者整合性照護指引（integrated care for older people, ICOPE），推動長者整合式功能評估工作，預防及延緩長者失能，減少對醫療照護的依賴，促進健康老化、在地老化和活躍老化。屏東縣因受城鄉醫療差距限制，運用公私協力方式委由單一窗口推動ICOPE篩檢與複評工作，推動策略分為準備期、行動期、執行修正期、推廣期等四個階段，並整合在地社區端和醫療照護體系端資源，提供後續進階評估與健康醫療服務，幫助長者早期發現內在功能衰退問題並及早介入處置。截至2024年8月ICOPE收案人數達11,873人，涵蓋率達7.42%。目前偏鄉社區面臨ICOPE篩檢後，異常個案的後續照護服務極度缺乏轉介銜接機制，以及相關社區護理人才培訓和投入，實為重大挑戰，亟待產官學研各界共同合作。ICOPE臨床實踐工作主要為確定社區中需要照顧的長者，以及照護歷程如何準備，社區護理師扮演關鍵角色，在面對與日俱增的老化人口，社區護理工作可能非常艱鉅，在推動健康台灣的願景下，政府政策應於社區護理的發展上挹注更多的投資與支持方案，以加速預防社區長者身心功能衰弱，落實健康老化的目標。

Population aging has become a prevalent societal trend in the 21st century, giving rise to intricate challenges for healthcare systems. Taiwan is expected to become a“super-aging society”in 2025. In 2020, the Health Promotion Administration, referencing World Health Organization (WHO) guidelines on integrated care for older people (ICOPE), began promoting person-centered functional assessments for older adults to prevent and delay disability, reduce reliance on formal healthcare, and promote healthy aging, aging in place, and active aging. Pingtung County faces a healthcare gap between urban and rural areas. To address this, the county’s executive team integrated community and healthcare systems into a single Age-Friendly Health Network to help older adults self-detect intrinsic functional decline problems at an early stage and receive early treatment. The implementation of this network is being done in the following four phases: preparation, action, implementation and revision, and promotion. As of August 2024, ICOPE intake in the county reached 11,873, representing a coverage rate of 7.42%. In addition to inadequate training opportunities for community healthcare professionals, rural communities are currently confronted with a dearth of referral mechanisms for post-ICOPE screening aftercare services for anomalous cases, representing a significant challenge that demands collaboration between industry, government, academia, and research. In light of the expanding older adult population, community nursing can be a formidable undertaking, necessitating the provision of ongoing nursing professional training and psychosocial support.