面對中期醫(yī)療照護(hù)之挑戰(zhàn)

1、面對中期醫(yī)療照護(hù)之挑戰(zhàn)臺北榮民總醫(yī)院高齡醫(yī)學(xué)中心家庭醫(yī)學(xué)部老年醫(yī)學(xué)科陳亮恭2022/9/221.案例分析82歲男性，與妻住於五樓老公寓高血壓，糖尿病，退化性關(guān)節(jié)炎與攝護(hù)腺肥大血壓控制：110/56 mmHg血糖控制：A1c: 6.1%目前用藥：Irbesartan/Dihydrochlorothiazide (Co-Aprovel)Amlodipine (Norvasc)Glibenclamide (Euglucon)Metformin (Glucophage)Phenoxybezamine (Dibenyline)Celecoxib (Celebrex)因暈眩而反覆跌倒髖關(guān)節(jié)骨折經(jīng)人工關(guān)節(jié)置

2、換術(shù)後出院出院後行動不便無法來院復(fù)健因持續(xù)暈眩而臥床再次住院第三級褥瘡胃潰瘍貧血吸入性肺炎敗血性休克22022/9/22.功能退化：25-35% 損失一項ADL醫(yī)源性傷害：50%以上住院15天以上內(nèi)科老年住院病患會出現(xiàn)認(rèn)知功能障礙：25%老年住院病患會出現(xiàn)認(rèn)知功能障礙情緒障礙：20-25%老年住院病患出現(xiàn)情緒障礙活動與行走障礙：所有老年住院病患均具有風(fēng)險營養(yǎng)不良：20-40%老年住院病患出現(xiàn)營養(yǎng)不良約束：所有約束均與病患不良治療結(jié)果有關(guān)高齡民眾罹患急性疾病的病程2022/9/223.長期住院是高齡化社會常見現(xiàn)象長期療養(yǎng)病房，由健保與長照保共同負(fù)擔(dān)，平均住院日約為60天2012年後長期療養(yǎng)病房的

3、設(shè)置取消，醫(yī)院與長照機(jī)構(gòu)徹底分割過去廣泛設(shè)置有Long-stay geriatric unit，然而英格蘭與威爾斯已無此類病房，但蘇格蘭依然存在老人長住病房人口老化壓力與臺灣相近，制度設(shè)計尚不健全。醫(yī)院體系中有老年醫(yī)學(xué)科、老年病醫(yī)院、老年護(hù)理醫(yī)院，後者可住院長達(dá)10餘年2022/9/224.臺灣現(xiàn)行高齡民眾健康照護(hù)體系2022/9/225.急性照護(hù)亞急性照護(hù)(Inpatient)急性後期照護(hù)(Community)Interim careIntermediate care末期照護(hù)長照體系社區(qū)獨立生活末期照護(hù)世界各國照護(hù)模式比較2022/9/226.全民健康保險現(xiàn)行臺灣照護(hù)模式急性醫(yī)療肺炎（急性醫(yī)

4、療）5.5 住院日肺炎（急性醫(yī)療）10-14 住院日肺炎（亞急性醫(yī)療）12.7 住院日急性醫(yī)療亞急性醫(yī)療(住院治療)急性後期照護(hù)(社區(qū)照護(hù))美國照護(hù)模式Medicare中期照護(hù)之國際間比較2022/9/227.混淆的名詞Sub-Acute在急性醫(yī)院設(shè)立亞急性照護(hù)單位或是在醫(yī)院附設(shè)的照護(hù)中心提供住院醫(yī)療服務(wù)亞急性照護(hù)的門診醫(yī)療服務(wù)Post-Acute提供社區(qū)為主體的照顧服務(wù)以協(xié)助病患在出院後能盡速回復(fù)功能目標(biāo)在於避免短期再入院Inter-rim暫時性的支持與積極性的介入服務(wù)適切的醫(yī)療與護(hù)理照護(hù)以維持即將進(jìn)入長期照護(hù)體系個案的最佳生活功能2022/9/228.A range of services

5、 designed to facilitate transition from hospital, and from medical independence to functional independence, where the objects of care are not primarily medical, the patients discharge destination is anticipated, and a clinical outcome of recovery (or restoration of health) is desired. 中期照護(hù)的定義2022/9/

6、229.中期照護(hù)的需求2022/9/2210.Joint workingCultural cleavages between professions, but dialogues resolvesMedical care and long-term care needsThe Danish system of care for older persons: Municipalities pay hospital patients awaiting LTCF placementCooperation contracts informed communities 3 days before dis

7、charge“Geriatric teams”: DP, 24-hours integrated community careGP: rarely involved unless for disease treatment中期照護(hù)推動的策略2022/9/2211.Opening the institutesFamily members trigger needs for new types of support systemsNeighborhood-centers providing all kinds of services and facilitiesThe Dutch: promoti

8、ng the concept of care-friendly districtsThis approach concerns the housing/care-interface which, in medicalized concepts, is often being neglected.Respective policies have led to interesting partnershipsGreek: aim at preventing isolation of the elderly promoting an integrated centre for prevention,

9、 health promotion, and social integration中期照護(hù)推動的策略2022/9/2212.Supporting informal careFamilies / informal carers in integrated care networks is crucial.Both prevention and the actual care: No professionalized service is able to completely cover all long-term care needsSupport mechanisms may vary fro

10、m cash benefits (UK, some regions in Italy) and pension grants (Germany) to training and information, employment (Nordic countries), and respite services such as day-care or short-term care but at very poor levels.The integration of informal care is remaining a critical area for integrated care deli

11、very中期照護(hù)推動的策略2022/9/2213.中期照護(hù)的模式Day hospitalDay rehabilitationTransportation assistanceCommunity rehabDomiciliary careCommunity rehab team neededNurse-led unitLook after post-discharge ptLess cost-effectiveBMJ 2005;330:699-703Community hospitalLow-intensity medical treatmentPrimarily rehabAs effecti

12、ve as district generalSignificant function improvementBMJ 2006;333:228-32BMJ 2005;331:317-22Hospital-at-homeDay hospitalCommunity rehab teamNurse-led unitResidential careCommunity hospitalUK ModelTaiwan Pilot2022/9/2214.醫(yī)學(xué)中心公立醫(yī)院老人住宅社區(qū)民眾中期照護(hù)試辦管理中心設(shè)於臺北榮總之下資料管理中心專家諮詢小組公立醫(yī)院體系榮總榮院榮家社區(qū)榮民退輔醫(yī)療體系社區(qū)醫(yī)療群第六期醫(yī)療網(wǎng)原

13、始方案護(hù)理之家功能強(qiáng)化護(hù)理之家遠(yuǎn)距醫(yī)療護(hù)理之家2022/9/2215.中期照護(hù)試辦管理中心退輔會第六處資料管理中心專家諮詢小組署立醫(yī)院體系榮總榮院榮家社區(qū)榮民退輔醫(yī)療體系第六期醫(yī)療網(wǎng)現(xiàn)行方案護(hù)理之家功能強(qiáng)化護(hù)理之家遠(yuǎn)距醫(yī)療護(hù)理之家署立桃園護(hù)理之家署立屏東護(hù)理之家三所榮總五所榮院衛(wèi)生署專家諮詢小組2022/9/2216.社區(qū)醫(yī)院中期照護(hù)172022/9/22.社區(qū)醫(yī)院中期照護(hù)182022/9/22.專業(yè)團(tuán)隊的建立192022/9/22.2022/9/2220.2022/9/2221.2022/9/2222.初步成效232022/9/22.高齡髖關(guān)節(jié)骨折照護(hù)242022/9/22.高齡髖關(guān)節(jié)骨折患

14、者社區(qū)照護(hù)252022/9/22.護(hù)理機(jī)構(gòu)的挑戰(zhàn)Challenges for nurse-led unit providing intermediate care servicesCompletely different residentsEmphasis on functional recovery but not long-term nursing carePost-acute patients are not in stable long-term care conditionLink with acute care servicesMulti-disciplinary team approachNeed for intensive physical re-ablement program 2022/9/2226.整合型照護(hù)服務(wù)的施行對象將整合性照護(hù)團(tuán)隊服務(wù)模式在社區(qū)長期照護(hù)機(jī)構(gòu)推動住民均為嚴(yán)重失能的長期臥床個案針對此類機(jī)構(gòu)住民而言，整合性照護(hù)服務(wù)實際效果相當(dāng)有限Wu, et al. Arch Gerontol Geriatr 2009 (accepted)2022/9/2227.態(tài)度基層高齡醫(yī)學(xué)照護(hù)急性醫(yī)療亞