面对中期医疗照护之挑战

1、面對中期醫療照護之挑戰台北榮民總醫院高齡醫學中心家庭醫學部老年醫學科陳亮恭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，退化性關節炎與攝護腺肥大血壓控制：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節骨折經人工關節置

2、換術後出院出院後行動不便無法來院復健因持續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醫源性傷害：50%以上住院15天以上內科老年住院病患會出現認知功能障礙：25%老年住院病患會出現認知功能障礙情緒障礙：20-25%老年住院病患出現情緒障礙活動與行走障礙：所有老年住院病患均具有風險營養不良：20-40%老年住院病患出現營養不良約束：所有約束均與病患不良治療結果有關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象長期療養病房，由健保與長照保共同負擔，平均住院日約為60天2012年後長期療養病房的

3、設置取消，醫院與長照機構徹底分割過去廣泛設置有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台灣相近，制度設計尚不健全。醫院體系中有老年醫學科、老年病醫院、老年護理醫院，後者可住院長達10餘年2022/9/224.台灣現行高齡民眾健康照護體系2022/9/225.急性照護亞急性照護(Inpatient)急性後期照護(Community)Interim careIntermediate care末期照護長照體系社區獨立生活末期照護世界各國照護模式比較2022/9/226.全民健康保險現行台灣照護模式急性醫療肺炎（急性醫

4、療）5.5 住院日肺炎（急性醫療）10-14 住院日肺炎（亞急性醫療）12.7 住院日急性醫療亞急性醫療(住院治療)急性後期照護(社區照護)美國照護模式Medicare中期照護之國際間比較2022/9/227.混淆的名詞Sub-Acute在急性醫院設立亞急性照護單位或是在醫院附設的照護中心提供住院醫療服務亞急性照護的門診醫療服務Post-Acute提供社區為主體的照顧服務以協助病患在出院後能盡速回復功能目標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適切的醫療與護理照護以維持即將進入長期照護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. 中期照護的定義2022/9/

6、229.中期照護的需求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中期照護推動的策略2022/9/2213.中期照護的模式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.醫學中心公立醫院老人住宅社區民眾中期照護試辦管理中心設於台北榮總之下資料管理中心專家諮詢小組公立醫院體系榮總榮院榮家社區榮民退輔醫療體系社區醫療群第六期醫療網原

13、始方案護理之家功能強化護理之家遠距醫療護理之家2022/9/2215.中期照護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院體系榮總榮院榮家社區榮民退輔醫療體系第六期醫療網現行方案護理之家功能強化護理之家遠距醫療護理之家署立桃園護理之家署立屏東護理之家三所榮總五所榮院衛生署專家諮詢小組2022/9/2216.社區醫院中期照護172022/9/22.社區醫院中期照護182022/9/22.專業團隊的建立192022/9/22.2022/9/2220.2022/9/2221.2022/9/2222.初步成效232022/9/22.高齡髖關節骨折照護242022/9/22.高齡髖關節骨折患

14、者社區照護252022/9/22.護理機構的挑戰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.整合型照護服務的施行對象將整合性照護團隊服務模式在社區長期照護機構推動住民均為嚴重失能的長期臥床個案針對此類機構住民而言，整合性照護服務實際效果相當有限Wu, et al. Arch Gerontol Geriatr 2009 (accepted)2022/9/2227.態度基層高齡醫學照護急性醫療亞