頁籤選單縮合
題名 | 無縫接軌之創新出院準備服務模式--以南部某醫學中心為例=Integrated Discharge Plan: Seamless Transition from Hospital to Home |
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作 者 | 魯英屏; 高詠彥; 王郁鈞; 王勁慧; 梁志光; 周明岳; 黃美智; 林麗英; 林育德; 陳芬婷; 林妙玲; 李素華; 黃志中; 顧艷秋; | 書刊名 | 臺灣老年醫學暨老年學雜誌 |
卷期 | 13:4 2018.11[民107.11] |
頁次 | 頁253-264 |
分類號 | 419.7 |
關鍵詞 | 老年人; 出院準備服務; 長期照護; 跨專業團隊; 無縫接軌; Elderly; Discharge plan; Long-term care; Transition care; Interdisciplinary team; |
語文 | 中文(Chinese) |
中文摘要 | 高齡長者常因為疾病關係住院而產生失能,出院後需要安排長照服務。然而,當失能長者返家時,如需接受居家式長照服務,需要等待照管中心安排長照管理專員訪視與服務遞送,因而產生照顧上的空窗期,造成家屬壓力。因此,醫院透過與地方政府與長照服務單位相互合作,讓出院準備服務與居家式長照服務無縫接軌,出院前完成長照需求評估與核定,並安排好各項居家式長照服務,完成長照服務遞送單位交班聯繫,讓失能長者在出院時可立即獲得服務,減少不確定性與空窗期,使長者與家屬能安心返家。 |
英文摘要 | Elderly patients often become disabled during hospitalization and dependent on long-term care service after discharge. However, when that happens, the current practice requires a disabled elderly patient to be discharged first and then wait for a certain period of time during which a case manager is assigned to visit the patient for assessment his or her need for home-based long-term care service. The service is delivered when the assessment deems it necessary. The practice creates a "gap" between hospital discharge and service delivery that causes considerable anxiety and stress for the patient's family members. If the assessment and arrangement for home-based long-term care service can be conducted prior to discharge, elderly patients will be able to expect with certainty the needed long-term care service upon returning home. Therefore, hospital, competent government authority, and service provider should be integrated into seamless cooperation to facilitate no-gap timely delivery of home-based long-term care services for elderly patients and their families. |
本系統之摘要資訊系依該期刊論文摘要之資訊為主。