長照復能服務跨專業協作的現況與未來挑戰

Transdisciplinary collaboration in long-term care reablement: Current situation and future challenges

「復能」是以個案目標為導向，透過跨專業團隊介入將服務輸送至長照使用者居家及社區。臺灣於2016年導入復能服務，期望幫助使用者恢復執行日常生活的能力，復能跨專業連結現況值得被探討。本文依據霍爾四階段跨專業團隊理論模型，說明和分享新北市長照專業照顧人員跨專業個案研討課程設計經驗，並且針對跨專業協作狀況，提出實務分析和政策建議，包括：（1）長照復能專業人員角色定位從執行者轉為諮詢者、（2）強化個管人員和專業照顧人員對於長照復能個案連結機制、（3）在學與在職教育應重視跨專業協作能力培養。臺灣長照2.0導入復能服務，並視為居家照顧新典範模式，建議應改善跨專業實體對話環境，才能有效提升照顧品質整合。

Reablement is defined as a goal-oriented intervention using a transdisciplinary team approach in the home and surrounding community of long-term care service users. In 2016, Taiwan introduced reablement with the objective of helping service users regain the ability to perform daily activities. The current transdisciplinary team approach involving long-term care professionals’delivery of reablement services requires further understanding. This study demonstrated a sample of course design regarding a transdisciplinary case study of long-term care professionals in New Taipei City using Hall’s four-phase transdisciplinary team-based model. Furthermore, we analyzed the practical aspects of transdisciplinary collaboration and provided policymaking recommendations to address the following issues: (1) the roles of long-term care professionals in reablement have changed from that of hands-on operators to hands-off consultants; (2) the mechanism for filling knowledge gaps between case managers and long-term care professionals in reablement services needs to be strengthened; and (3) the competence of transdisciplinary collaboration during in-school and in-service education needs to be addressed. Taiwan has implemented reablement as a new mode of home care service under the policy of Taiwan’s Long-Term Care Plan Version 2.0. Improvements in the physical environment of communication among transdisciplinary professionals are required to facilitate the integration of quality care.