居家照护服务模式--以台湾中部某医学中心为例

医疗资源的有限及医疗费用高涨,使得居家照护再次受到重视。彰化基督教医院于1971年起,即将居家护理的观念及模式,由妇幼的形态范围扩展至内、外科,提供慢性病患者长期的居家照护服务,成为台湾地区发展“居家照护”服务的先驱。全民健康保险开办以来,将居家照护纳入给付的范围,患者只需支付少额金钱,便能享受医师及护理人员提供上门服务,实为行动不便者的一大福利。彰化基督教医院居家照护团队主要由家庭医学科医师及居家护理师组成,另包括营养师、社工师、复健师、心理师、关怀师及各专科医师为咨询对象,提供跨团队的专业服务。我们目前提供的服务包括:慢性病行动不便者之居家照护,癌症末期病患之居家照护及早产儿居家照护。病患来源主要来自住院患者转介,亦接受其他医院转介,或患者自行求诊。借由计算机化科技的协助,患者得以获得适当转介,加以完整的团队服务流程,提供个案连续性照护。以慢性病行动不便者之居家照护为例,我们每月约服务250人,居家照护次数约350次;每年约服务400人以上的个案,居家照护人次平均高达4000人次以上;使患者及其家属得到周全性、可及性、持续性、协调性及负责性的照护及追踪。

Home Care Service Model in a Medical Center of Middle Taiwan

With the development and progressing of medical technology and care skill,the life expectancy of people is increasing,and chronic diseases have been the main medical issues in the 21st century.Most of chronic diseases will result in complications,which need long-term care.With the limited medical resources and growing medical expenditure,care at home has been paid much attention again.Changhua Christian Hospital is the first medical organization that provides home care service in Taiwan since 1971.The members of home care team include physicians,home care nurses,social workers,dieticians,therapists,and other specialists.We provide service at home for disabled people with chronic disease,cancer patients with terminal stage,or premature neonates.With the assistance of computerized consulting system,the patients can be referred properly.Under the interdisciplinary team care model,we provide the patients and their family comprehensive,accessible,coordinative,accountable and continuous long-term care.We serve about 400 families and provide 4000 visits yearly.Under the home care service model,we extend our medical service from the hospital to the community,and make the hospital become a no barrier hospital.