高齡出院準備計畫服務之探討

摘要

Based on practical application, this study assists senior adults to successfully be transferred to other caring environment after medical treatment in order to ensure that after leaving the hospital, they can receive continuous and positive health care service. Thus, their families’ caregiver burden can be reduced. Regarding the construction of senior adults’ discharge planning, based on the principles and service content of literatures, this study develops the primary process as follows: 1) improvement of discharge planning; 2) reinforcement of discharge support; 3) reinforcement of transfer after discharge, as tracking care and outcome evaluation after discharge. Senior adults’ discharge planning constructed by this study can effectively lower their internal obstacles (increase of compliance rate and hospitalization rate, helpless families and senior adults or lack of knowledge of care and negative family relationship) and external obstacles (lack of medical information and psychological support for the families), which can be integrated in current discharge service and it is effective for senior adults’ mobility.本文以實務應用導向針對高齡長者在就醫後，協助其順利轉至另一個照護環境，確保其在出院後能獲得持續與良好的健康照顧服務，進而讓家屬能減輕照顧負荷。因此，在高齡長者接受所規劃的出院準備服務流程之建置，先參照文獻之原則、照顧需求及服務內涵後擬定初步流程為：1. 改善出院準備計畫；2. 強化出院後支持；3. 強化出院後轉介的銜接，以做為出院後追蹤照護及成效評值。本文所規劃之高齡長者參與出院準備計畫能有效降低其內在障礙問題(就醫率及住院率上升、家屬和高齡長者本身無力或不知如何照顧、家庭關係失和)與外在障礙問題(提供就醫資訊不充足、應給予家屬心理支持)，值得整合於現有出院準備服務中，並對高齡長者有具體行動力(mobility)的成效。