提升急診後送病房出院前3天銜接長照2.0評估之完成率

Increase the Completion Rate of Long-term Care Evaluation 3 Days Prior to Hospital Discharge in Medical Wards

政府推動「出院前3天完成長照需求評估」，使有長期照顧需求的病人於急性醫療處置後出院返家就能銜接長照服務。本院2019年8-9月急診後送病房出院前3天銜接長照2.0評估之完成率僅43.8%，分析完成率低的原因包括出院日期不確定性、家屬對長照2.0知識不足及醫護人員對長照2.0知識不足。經由專案之推動提供病房符合長照2.0收案條件名冊、參與多團隊會議討論、使用確認申請服務單張、張貼與運用含影片連接之宣導海報、提供諮詢專線及舉辦在職教育課程等措施後，評估完成率於2020年5-7月提升至75%。建議未來串連資訊提醒機制，及時警示病人銜接長照2.0之需求，以有效提升出院前3天銜接長照2.0評估之完成率，使病人出院服務即到家，減輕病人家屬返家後照顧之問題。

Facing a rapid aging society, the Taiwan government has launched a long-term care 2.0 plan and aims to provide patients discharged from the hospital a continuum of community-based care. One of key quality indicators of the plan is to complete the assessment of need for long-term care at least 3 days prior to hospital discharge. During August and September 2019, only 43.8% of patients achieved the aforementioned criterion. The main obstacles to achieve the goal included indeterminate date of patient discharge from the hospital and family and healthcare provider’s insufficient knowledge about the long-term care plan. Thus, we initiated an improvement project, incorporating attendance of multidisciplinary team meetings, continuing education, online counselling, provision of flyers and posters, and target population identification, to improve the indicator. Following the improvement measures, the proportion of patients who met the quality indicator significantly increased to 75% during May and July 2020. In summary, this study suggests the effectiveness of our project to improve the coverage rate of a long-term care assessment for hospitalized patients in need.