出院準備服務銜接長照居家復能之腦中風個案照護經驗

An Experience of Discharge Planning Service in Transition to Long-Term Care Home Reablement in Stroke Cases

本研究探討一位79歲男性腦中風導致右側肢體偏癱失能個案，出院準備服務個管師協助返家後人、事、物準備及長照2.0評估服務，以利個案出院返家無縫接軌銜接長照資源。護理期間自2020年3月11日至2020年5月18日，運用照顧管理評估量表進行整體性評估，瞭解個案及照顧者身、心、環境、社會支持及醫療照護等需求，確立主要健康問題為身體活動功能障礙、自我照顧缺失及照顧者角色緊張，並進行長照服務失能等級評估，依其等級及早轉銜長照資源。於護理過程把握腦中風黃金復健期，進行居家復能，執行個別化的復能計畫，以促使個案盡快恢復功能，並持續進行出院後電話追蹤確認返家後續照顧情況，主動關懷傾聽主要照顧者的壓力及焦慮，增進居家照護技巧、主要照顧者信心，降低照顧負荷，提升日常生活品質，藉此經驗有助於提升護理人員瞭解出院準備服務銜接長照2.0資源，透過及早介入對個案復能更具成效。

The discussed subject in this article is a 79-year-old man with stroke-related right side hemiplegia. His discharge planner assisted for a seamless transition to long-term care 2.0 resources after his hospital discharge. During the nursing period from March 11 to 18, 2020, the multidimensional assessment instrument (MDAI) was applied for an overall assessment to understand the subject and the caregiver’s physical, mental, environmental, social support and medical care needs. The main health problems were identified as impaired physical mobility, self-care deficit, and the caregiver role strain. Furthermore, the long-term care service disability level assessment was carried out for a timely transition to long-term care resources based on the assessed level. Early reablement intervention of stroke during the nursing process, home reablement program, and individualized reablement exercise plan were all helpful for promoting the timely function restoration. Continuous follow up after hospital discharge for monitoring home care quality and active caring and listening to the stress and anxiety of the main caregivers may improve home care skills and the confidence of the main caregivers to reduce care load and improve the daily life quality. This nursing experience may improve the understanding of nursing staff reagarding discharge planning in transition to long-term care 2.0 resources. A more effective reablement may be achieved through an early intervention.