法學期刊
論著名稱: 基層醫療推動預防失能之慢性病計畫成效探討(Effectiveness of Implementation of Prevention/Delay Disability Health Care Service for Older Patients With Chronic Diseases In The Primary Health Care Setting In Taiwan)
編著譯者: 李純瑩莊昀璇方姿蓉李洮俊李惠蘭吳建遠賈淑麗王英偉
出版日期: 2021.03
刊登出處: 台灣/醫療品質雜誌第 15 卷 第 2 期 /34-39 頁
頁  數: 6 點閱次數: 19
下載點數: 24 點 銷售明細: 權利金查詢 變更售價
授 權 者: 財團法人醫院評鑑暨醫療品質策進會 授權者指定不分配權利金給作者)
關 鍵 詞: 慢性整合照護老年周全性評估基層照護衰弱
中文摘要: 目的:本研究期望建構適合我國基層醫療之老年人照護模式,壓縮長者失能時間,降低醫療照護負擔。
材料與方法:10 群社區醫療群針對具三高(高血壓、糖尿病、高血脂)之一高且 65 歲以上長者進行 WHO 10 分鐘量表篩檢及檢視個案多重用藥問題,診所依照評估結果提供適當介入,並在至少 60 天後追蹤後續狀態。
結果:12,506 位長者平均年齡為 74.6±6.9 歲,女性占 61.9%,29.4% 長者為多重慢性病用藥者,評估結果個案有任一項異常的比例為 66.7%。其中 6,247人 經過介入服務 60 天後再次追蹤評估,整體結果為「改善」有 43.44%,「不變」有 25.16%,「惡化」有 9.0%,前後都「正常」則有 22.39%。
結論:基層診所具有篩檢及發現個案的量能,介入後各指標皆能在短期內獲得改善,而長期預防延緩失能的效果則有待更長時間追蹤。
英文關鍵詞: integrated carecomprehensive geriatric screeningprimary carefrailty
英文摘要: Objective: This study aimed to develop a community health care-based integrated care model for older patients to limit the occurrence of disability in this group and promote healthy aging in Taiwan.
Methods: Ten primary care group practices participated in this study. The primary care doctors and staff were trained to conduct a brief comprehensive assessment and management of older people. Patients eligible for evaluation were those aged ?65 years with at least one of the following diseases: hypertension, diabetes mellitus, and hyperlipidemia. The assessment included a 10-minute comprehensive screening test, a frailty examination, and a medication review. A care plan was developed based on the results. Patients were followed-up after 60 days.
Results: In total, 12,506 participants were enrolled; their mean age was 74.6 ± 6.9 years, 61.9% were female, and 66.7% had at least one abnormal assessment. After suitable intervention, 6,247 participants were followed-up in 60 days. The data revealed that after intervention, the condition of 43.4% of the patients improved, 25.16% remained abnormal, and 22.39% remained normal; only 9.0% of the patients experienced a deterioration of their condition.
Conclusions: Our results indicate that comprehensive geriatric assessment and care planning delivered by primary health care providers is effective and practicable.
目  次: 摘要
前言
材料與方法
研究結果與討論
參與診所
老年個案
結論
誌謝
參考資料
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