邁向整合照護：台灣居家與社區式服務（HCBS）組合型態與醫療費用之分析──以全國性資料世代研究為基礎

Association between approved home- and community-based service patterns and changes in health-care costs: a national databased cohort study in Taiwan

目標：本研究旨在探討不同居家與社區式服務（home- and community-based services, HCBS）核定服務組合型態與高齡照顧接受者醫療費用變化之關聯。方法：使用台灣長期照顧十年計畫1.0資料庫與全民健康保險申報資料，分析2009–2014年之世代資料。研究樣本為106,578名首次申請HCBS，且於接受服務核定時年齡≥65歲者。採用潛在類別分析辨識相似HCBS核定服務組合型態，並以多元線性迴歸分析其與醫療費用變化之關聯；醫療費用變化係以核定後第4至第15個月減核定前12個月計算。結果：辨識出四種HCBS核定服務組合型態：居家服務照顧（home-based personal care, PC）、居家專業照顧（home-based medical care, MC）、PC/MC，以及社區式照顧。與PC/MC組相比，MC組在總醫療費用（β=−42,842.00，p < .0001）、急診費用（β=−699.14，p < .0001）及住院費用（β=−43,091.00，p < .0001）呈現顯著較大降幅；而PC組與社區式照顧組的醫療費用之變化，多數未達統計顯著差異。結論：以專業照護服務為主的HCBS核定服務組合型態，與醫療費用支出下降幅度較大相關，可作為未來推動HCBS專業照護整合與服務協調之參考。

Objectives: This study examined the association between approved home- and community-based service (HCBS) patterns and changes in health-care costs among older adults receiving care services. Methods: We analyzed cohort data from two national databases in Taiwan: the Ten-Year Long-Term Care Plan 1.0 database and the National Health Insurance Program claims data collected between 2009 and 2014. The sample included 106,578 care recipients who were first-time HCBS applicants and aged≥65 years at service approval. Latent class analysis was performed to identify similar approved HCBS service patterns, and multiple linear regression was used to examine their associations with changes in health-care costs. Changes in health-care costs were calculated by subtracting costs incurred during the 12 months before service approval from costs incurred during months 4–15 after service approval. Results: Four approved HCBS service patterns were identified: home-based personal care (PC), home-based medical care (MC), combined PC/MC, and community-based care. Compared with the combined PC/MC group, the MC group exhibited significantly greater reductions in total health-care costs (β=−42,842.00, p < .0001), emergency department costs (β=−699.14, p < .0001), and hospitalization costs (β=−43,091.00, p < .0001). Most changes in health-care costs in the PC and community-based care groups did not significantly differ from those in the PC/MC group. Conclusions: Approved HCBS service patterns primarily characterized by professional care services were associated with greater reductions in health-care expenditures. These findings may inform future efforts to integrate professional care services within HCBS and strengthen service coordination.