失智症日間照顧服務使用狀況與其評估－－以嘉義聖馬爾定與三鶯地區健順失智症日間照顧中心為例

Use and Evaluation of Day Care Services by Older People with Dementia-Two Empirical Experience

行政院建構長期照護先導計畫將失智症日照中心列為實驗社區試辦與發展的九種服務措施項目。本研究配合先導計劃對失智症日照中心進行使用了解與評估。採用Donabedian評估照顧品質之途徑—結構、過程與結果評估。由於結果評估中功能變遷操作之不易，本研究以使用者滿意度取代之。同時本研究亦檢視服務提供者的提供經驗，所面對的困難和解決策略。研究採問卷調查法、訪談法、焦點座談法與次級資料分析法的方式進行。研究工具為參考國內外文獻並自行設計之半結構式問卷，另輔以開放性訪談。問卷係根據契約書規定和理想上之服務面向與細項分別設計，訪談則以開放性為原則，廣泛探討服務使用者與不使用者之原因。
嘉義失智症日照中心是由在地聖馬爾定醫院所附設，一則容易接觸到案主群，一則採醫院模式照顧，重視患者的照顧、復健和健康評估。三鶯日照中心則是由外來機構健順養護中心新辦。由於缺乏與醫院看診的直接連結，個案均由實驗社區照顧經理轉介而來，採用社會模式的照顧，較強調社會性的活動，老人較無機構化的約束。除了模式不同外，在使用日照服務上花費的金額及使用原因略有不同，可能與使用者的社經地位高低有關。
從本研究中可知，硬體設施和服務過程與服務內容上大都能符合要求，兩地使用者均對日照服務抱持高度的評價，使用的原因方面，以接受日照服務可以直接減輕家屬的照顧負擔為最主要。
兩地未使用日照服務的原因均包括：「不符合實驗社區失智日照中心服務巴氏量表70分的收案標準」、「案家缺乏動機帶個案進行失智鑑定」、「家庭有照顧人力」、「覺得日照服務是機構式的標籤化」、「民眾對日照服務陌生，懷疑日照服務的功能」、「覺得收費費用太高」等共同原因。
「案源不足」是兩地服務提供共同的問題，也均透過「加強案量開發」與「定期與相關單位（社會局、實驗社區）舉辦聯繫會報」等解決策略以克服困難。最後，本研究比較兩個中心的使用者、使用原因、未使用者原因後，並提出實務上的建議。

This study examined the use and evaluation of the day care centers (DCCs) in two Taiwanese communities. DCCs were given prominence in a recent initiative: The Pilot Program of Long Term Care of the Executive Yuan set [Aging in place] as the primary goal and planned to construct the system strategically in three years. DCCs were prioritized for Dementia patients as among other nine newly developed facilities or service programs for the disabled elderly in two experimental communities.
The study used Donabedian's approach to measure the quality of care in terms of structure, process, and outcome. Subjective evaluation of user satisfaction was the methodological component of the study. In the evaluation of two DCCs, current primary caregivers were surveyed by using semi-structured questionnaire, including service content cited in the contract and in the literature. Providers were also interviewed about their experiences and difficulties in providing day care services as well as the resolution of difficulties. Focus groups of community care managers and secondary data from two DCCs were also utilized. In addition, factors of whether or not services were used were also explored.
Two Centers with different organizational models were used as study sites. Chiayi Day Care Center was affiliated with a hospital and adopted the medical adult day care model. This model focused on patients' care, rehabilitation and health evaluation. San-Ying Day Care Center, not affiliated with a hospital, adopted the social adult day care model, and prioritized a variety of social activities. There were important differences between the two centers in the flow of patient referrals, the underlying rationale for providing services and the overall costs of providing service. At least one explanation of the differences may be related to different levels of socio-economic status of the two communities.
Highlights of important findings were:
(a) Reasons for using DCCs included lowering burden of caregivers, substituting for care during daytime;
(b) Reasons for not using DCCs when needed were: Barthel's index score being below 70, families being resistant taking the elderly to do dementia evaluation, having family members to care, feeling DCCs as one kind of institutionalization, having doubt with DCCs' caring capability, and feeling the expenses being too high;
(c) When caregivers used Day care centers, almost all of them were satisfied with the center and services provided quantitatively, except some opinions where we used open questions.
The policy implications from these results were discussed.