北臺灣小兒復健公費與自費治療師對於服務現況與挑戰之探討：以協助身心障礙幼兒從早期療育轉銜至幼兒園為例

Exploring Service Practices and Challenges of Publicly and Privately Funded Pediatric Rehabilitation Therapists in Northern Taiwan: An Example of Supporting the Transition from Early Intervention to Preschool among Children with Disabilities

全民健康保險確保發展遲緩幼兒獲得必要之早療服務。為填補家庭龐大的早療需求，自費早療應運而生。然而目前缺乏公費與自費早療服務現況之比較。故本研究旨在探討兩者服務的現況差異，並以早期療育轉銜服務階段為例，具體呈現公費與自費體制對於早療實務之影響。研究者以質性研究法、半結構式訪談21位公費與自費治療師。並以主題分析法探究參與者對於早療服務之看法。研究發現，給付制度影響治療師平日之業務量、與幼兒家庭的關係建立，進而體現於治療師在家庭溝通、早療計畫設定、跨專業合作等早療實務。公費治療師受限於治療時程，缺乏足夠時間與家長溝通。而自費治療師則透過多元溝通方式與家長建立合作關係。在跨專業合作上，由於公費多為綜合性的醫療院所、專業間溝通較為方便，故公費治療專業間的互動較自費治療密切。本研究以公費自費服務比較，協助家庭選擇早療服務，亦建議健保給付納入早療專業提供教育者專業諮詢之項目，以協助幼兒達到最大學習潛能。

Rationale & Purpose: In Taiwan, early intervention (EI) services for young children with developmental delays are delivered through two coexisting financing structures: publicly funded services reimbursed by the National Health Insurance (NHI) system and privately funded services primarily delivered by therapy clinics. Although the NHI system ensures basic accessibility, its global budget and point-value payment systems restrict treatment duration, increase therapist workload, and limit opportunities for family-centered collaboration. Concurrently, the rapid expansion of private EI clinics, often partially subsidized by local governments, has created wide variation in the flexibility, cost, and quality of available service models. Despite the simultaneous existence of two care systems, few scholars have compared how both financing structures influence EI service delivery, family communication, professional roles, and the transition from EI to preschool. This transition is a pivotal developmental juncture that requires coordinated support from medical, educational, and family systems. Prior scholarship in Taiwan has predominantly addressed the educational aspect of the transition, neglecting how payment systems influence therapists’ability to prepare families for preschool entry. To address this gap, the present study investigated EI service conceptualization and delivery practices among pediatric rehabilitation therapists working in public and private systems, particularly during the EI-to-preschool transition. The goals of the study were to (1) describe the service practices of public and private EI therapists, (2) explore the perspectives and experiences of EI therapists working under different payment systems, and (3) compare EI-to-preschool transition practices between the NHI and private EI sectors. Methods: This qualitative descriptive study conducted semi-structured interviews with 21 pediatric rehabilitation therapists (12 public and 9 private) in northern Taiwanese cities, including Taoyuan, Hsinchu, and Miaoli. Participants included occupational therapists, physical therapists, and speech-language pathologists, all of whom had at least 2 years of EI experience and were directly involved in supporting transitions to preschool. Participants were recruited through purposive sampling and referrals from hospitals, therapy clinics, and school-based professional teams. Data were collected between June and November 2023 during six group interviews and three individual interviews focusing on daily EI service practices, family communication, cross-professional collaboration, constraints imposed by payment systems, and transition-related experiences. To mitigate bias, interviewers initially discussed transition practices without disclosing the comparative intent of the study; differences between public and private systems were discussed only in the final interview section. All interviews were audio-recorded, transcribed verbatim, anonymized, and thematically analyzed using MAXQDA. Coding was performed independently by two researchers through iterative consensus meetings, peer debriefing, reflective memoing, and member verification, with reference to credibility, dependability, and confirmability criteria. Transition-specific codes were based on Bronfenbrenner’s ecological systems theory and prior transition research. Data saturation was reached when no new themes emerged. Results: Substantial differences were observed between public and private EI service systems regarding scope of practice, professional development, service practices, and cross-system collaboration, all of which influenced therapists’effectiveness in supporting the EI-to-preschool transition. 1. Scope of practice and workload structures: Public therapists operated under rigid NHI constraints involving 30-minute treatment slots, high caseloads, limited control over scheduling, and extensive administrative responsibilities. These conditions restricted in-depth family communication and family-centered goal setting, forcing therapists to prioritize medically necessary, impairment-focused treatment. By contrast, private therapists had greater autonomy regarding session length (30–60 minutes), caseload size, and scheduling, allowing more time for counseling, education, and observation of family needs. A reduced administrative load enabled more comprehensive clinical reasoning and individualized planning. Because private clinics rely on client satisfaction, therapists consistently emphasized responsive communication and partnership-building with families. 2. Professional development and expectations: Private therapists were more likely than public therapists to pursue continuing education related to preschool curricula, classroom functioning, and transition requirements. Many private therapists built relationships with local preschools and engaged informally in school-based observations or activities. Public therapists had fewer opportunities to engage with the education sector owing to medical reimbursement limitations and institutional expectations. They expressed a strong desire for structural supports, such as school-based consultants stationed in hospitals, to facilitate information sharing and transition guidance. 3. Service practices and parent-therapist communication: Differences in communication structures strongly influenced transition services. Public therapists reported needing to restrict their communication to only a few minutes during treatment sessions, resulting in therapist-directed, child-centered planning and hindering rapport-building efforts. Parental motivation to consult with public therapists varied widely: some sought services to meet institutional requirements (e.g., school recommendation, transportation subsidies), and socioeconomic barriers sometimes limited home-based carryover. By contrast, private therapists used multimodal communication approaches (social media, phone calls, video demonstrations, and photos) to promote family-centered care. Parents often had fewer economic constraints and demonstrated high expectations, actively seeking guidance and collaboratively establishing functional, context-based goals. Emotional support for parents (e.g., coping with separation anxiety or school concerns) was highlighted as a central aspect of private EI work. Private settings also allowed for more detailed simulation of school environments; for example, therapists used child-sized toilets, school-like seating, and mock classroom routines to prepare children for the behavioral and functional demands of preschool. 4. Cross-professional and cross-system collaboration: Public hospitals are typically multidisciplinary, facilitating in-house collaboration between medical professionals. However, public therapists noted that formal case conferences often involve parallel reporting rather than genuine interdisciplinary problem-solving. Moreover, NHI reimbursement does not cover therapists’time spent externally collaborating with schools, decreasing their opportunities to directly interact with teachers. Although private clinics are often less internally multidisciplinary, they may benefit from therapists’dual roles as itinerant school-based providers. This positioning enabled participating private therapists to communicate continuously with preschools, gain a contextualized understanding of children’s needs, and provide practical guidance for families regarding school options and adaptation. 5. Transition-specific practices: Across systems, therapists viewed parents as the primary decision-makers during the EI-to-preschool transition, but differences in service structures influenced how therapists could offer support. Public therapists provided guidance only when asked by parents, and limited communication occasionally engendered mismatched expectations regarding school readiness. Private therapists proactively anticipated parent concerns, offered psychological support, tailored home programs for school preparation, and helped families compare educational placements. After preschool entry, public therapists often discharged children whose functional needs were not considered“medically significant,”whereas private therapists continued follow-up until the child demonstrated stable school adaptation. Conclusions and Implications: This is the first systematic comparison of public and private EI service models in Taiwan, demonstrating how financing structures influence transition practices. Despite the interdisciplinary infrastructure of public hospitals, time and administrative constraints under the NHI system limit opportunities for family-centered care, in-depth communication, and cross-system coordination. Private EI services, although costly and uneven in quality, offer greater flexibility, responsiveness, and alignment with family-centered and ecological care frameworks, which are crucial for successful school transitions. This study highlights the need for systemic reforms to better support the EI-to-preschool transition. Rigid NHI reimbursement rules limit family-centered communication, interdisciplinary collaboration, and transition planning, and private EI services, although comparatively flexible, are less accessible to economically disadvantaged families and exhibit quality variability. Policymakers should consider incorporating reimbursable items for transition consultation and cross-system communication into the NHI payment structure, extending or protecting time allocated for parent counseling, and developing standardized, nationwide transition guidelines that bridge medical and educational systems. Efforts to reduce regional disparities and strengthen interdisciplinary training would further improve service continuity and equity for children with developmental delays.