23卷3期

• Link 原著 Original Article
• 社會中失能者未滿足需求之盛行率與其相關因素Prevalence and Related Factors of Unmet Needs among the Disabled in the Community
• 莊坤洋、陳育慧、曹愛蘭、吳淑瓊
  Kun-Yang Chuang, Yu-Hui Chen, Ai-Lan Tsao, Shwu-Chong Wu
• 未滿足需求 ； 失能 ； 長期照顧
  unmet needs ; disability ; long-term care
• 目標：瞭解ADL與IADL未滿足需求的盛行率，並探討可能影響未滿足需求的相關因素。方法：研究對象為設籍在台北縣三峽鎮、鶯歌鎮、新店市、樹林市及嘉義市，且為50歲以上的失能者進行訪視調查，共2141位。結果：ADL未滿足需求的比例最低為洗澡（4.0%），最高為室內走動（29.9%）。 IADL未滿足需求的比例最低為煮飯（1.3%），最高為打電話（48.3%）。45.7%的研究對象至少有一項ADL未滿足需求，56.7%至少有一項IADL未滿足需求。邏輯式迴歸分析影響ADL未滿足需求之相關因素顯示，控制其他變項後，失能者的居住地區、ADL失能數目均為預測ADL未滿足需求的重要因素。影響IADL未滿足需求之分析結果顯示，控制其他變項後，失能者的教育程度、居住地區、罹患疾病數目、IADL失能數目，以及照顧者的教育程度、照顧者身分，均為預測IADL未滿需求的重要因素。結論：在社區中老年失能者末滿足需求盛行率頗高，家庭照顧者往往無法滿足失能者。因此，如何利用照顧管理機制為失能者適當地規劃非正式及正式資源，提昇失能者接受的照護服務品質，以減少未滿足需求盛行率，將是末來政府在長期照護體系發展上須重視的問題，如此才能落實「在地老化」的照護觀念。
  Objectives: To assess the prevalence of unmet needs in activities of daily living (ADL) and instrumental activities of daily living (IADL). Also, to identify the relevant factors of unmet needs. Methods: A total of 2141 disabled residents, age 50 or over, from 5 communities were interviewed regarding their ADL and IADL needs and unmet needs. Results: ADL unmet needs ranged from cooking (4.0%) to walking in the room (48.3%), and IADL unmet needs ranged from laundry (1.3%) to making phone calls (49.1%). Around 45.7% of respondents had at least 1 ADL unmet need, and 56.7% had at least 1 IADL unmet need. Multivariate analysis revealed that the location of residence, and the extent of disability were important predictors of ADL unmet needs. The predictors of IADL unmet needs were education, location of residence, number of chronic diseases, number of disabilities in IADL, caregiver’ s education, and relationship with the caregiver. Conclusion: The prevalence of unmet needs was generally high. In regard to system changes, increasing community-based care resources, and aggressive promotions to encourage its utilization may reduce the prevalence of unmet needs. Care management schemes could also be used to target the high-risk group and reduce their unmet needs.
• 169 - 180
• 10.6288/TJPH2004-23-03-01

• Link 原著 Original Article
• 社區認知障礙者之照護需要The Care Needs of People in the Community with Cognitive Impairment
• 張媚、吳淑瓊、莊坤洋
  Mei Chang, Shwu-Chong Wu, Kun-Yang Chuang
• 認知障礙者 ； 照顧需要 ； 照顧者負荷
  Cognitive impairment ; care needs ; caregiver's burden
• 目標：本研究目的在瞭解社區認知障礙者之照護需要及其主要照顧者對照護的看法。方法：研究資料取自建構長期照護體系先導計畫實驗社區之前測調查，共174位認知障礙者及其照顧者146人成為研究樣本。結果：（l）認知功能障礙者平均每人有2項ADL功能及5項IADL功能需人協助；心智及行為方面表現較差的是睡眠型態、衛生與修飾；57 .4％的人不能單獨留在家中超過3個小時。（2）複迴歸分析顯示認知障礙者的情緒情形等七項心智及行為狀況、ADL及 IADL 需要協助的分數及照顧者照顧年數等變項可以解釋照顧者負荷36.6％的變異量，對照顧負荷最顯著的預測變項是認知障礙者的情緒情形及照顧者照顧年數。（3）61.6％的照顧者認為最適合的照顧方式是在家中有人照顧。結論：為協助及支持照顧者繼續在家中照顧認知障礙者，應在社區中提供更多有關失智症的教育、指導及社區資源。
  Objectives: The purposes of this study were to understand the care needs of people in the community with cognitive impairment and also the needs of their caregivers. Methods: Secondary data drawn from a study entitled “Pre - investigation for Experimental Community in Pilot Program for the Development of Long Term Care System” was analyzed. The subjects were 174 community residences with cognitive impairment and along with their caregivers (n=146). Results: (1) For subjects with cognitive impairment, the average number of impaired ADL and IADL were 2 and 5 per subject, respectively. Sleeping pattern and personal hygiene were two major problems related to psychosocial behaviors. Most of them (57. 4 %) were not able to stay at home alone for longer than 3 hours. (2) Seven of the psychosocial behaviors, ADL scores, IADL scores and the length of duration they were cared explained the 36.6 % variation in the caregivers’ burden. (3) Most of the caregivers (61.6 %) believed that home was the best method of care for the subjects. Conclusion: More education and community resources regarding dementia are needed in order to assist caregivers to coutinue taking care of subjects at home.
• 181 - 187
• 10.6288/TJPH2004-23-03-02

• Link 原著 Original Article
• 失能者身體功能之評量－失能者與其家庭照顧者看法之比較Assessment of Physical Functioning in Disabled Persons - A Comparison between Self-Reports and Proxy Reports from Family Caregivers
• 呂寶靜
  Pau-Ching Lu
• 身體功能評量 ； 日常生活功能能力 ； 工具性日常生活功能能力 ； 評量方法
  functional assessment ; activities of daily living ; instrumental activities of daily living ; data collection
• 目標：本文係在比較分析失能者和其家庭照顧者對失能者身體功能的評量，身體功能評量的面向為日常生活活動能力和工具性日常生活活動能力，進而分析影響兩者評量一致性的因素。方法：本研究所使用之資料係來自「建構長期照護體系先導計畫第一年實驗社區前測資料」，分析之樣本僅選取自答的失能者，且又有主要家庭照顧者；計有743位失能者及其照顧者的配對，又資料之分析方法為 Cohen’ s kappa值檢定、配對樣本 T 檢定、及兩組積差相關係數T檢定。結果：失能者和其家庭照顧者對於失能者日常生活活動能力之評量一致性高，而對於工具性日常生活活動能力之評量一致性普通；其次，不論在日常生活活動和工具性日常生活活動能力方面，照顧者傾向低估失能者的能力。另外，配偶照顧者比起非配偶照顧者、同住照顧者比起不同住照顧者、提供較多協助之照顧者比起較少協助之照顧者，有較低的評量一致性。結論：評量失能者身體功能，透過代答者所收集來的資料之品質會受到評量工具之明確性、失能者或代答照顧者的特性、以及兩人關係等因素之影響。
  Objectives: The purpose of this paper was to compare the assessment of physical functioning as rated separately by disabled people and their family caregivers. The functional assessment included two major domains: activities of daily living (ADL) and instrumental activities of daily living (IADL). Furthermore, the purpose was to identify the factors that would influence the response agreement between proxy and subject reports for functional assessment. Methods: 743 disabled people and their caregiver’s dyad were selected from The Pilot Program for the Development of Long-Term Care System Baseline Survey. Inter-rater reliability (kappa) and the paired comparison test were employed for the purposes of data analysis. Results: The response agreement was relatively high for ADL assessment, and low for IADL assessment. Family caregivers generally rated a greater level of disability than the disabled people did. For non-spouse caregivers, those caregivers who lived with the disabled, and those who provided more assistance, the response agreement tended to be better than for their counterparts. Conclusions: When assessing the physical functioning of disabled persons, the quality of data collected via their caregivers will be affected by the clarity of the assessment tool, the characteristics of the disabled people and caregivers, as well as the relationship between the disabled people and their caregivers.
• 188 - 196
• 10.6288/TJPH2004-23-03-03

• Link 原著 Original Article
• 社區式照顧管理模式的設立與初步評價Establishment and Preliminary Evaluation of a Community-Based Care Management Model
• 戴玉慈、張媚、呂寶靜、吳淑瓊
  Yu-Tzu Dai, Mei Chang, Pau-Ching Lu, Shwu-Chong Wu
• 社區式長期照護 ； 照顧管理 ； 跨專業 ； 照顧經理
  community-based long-term care ; care management ; interdisciplinary ; care manager
• 目標：本行動研究目的在現劃與執行社區式長期照護的管理模式，並進行初步評價。方法：以協助民眾在地老化為宗旨，以跨專業團隊建立長期照護各專業分工模式，訓練照顧經理對失能者提供綜合評估、擬定照顧計畫、整合資源、協調服務、監測服務結果。在嘉義市與三峽鶯歌地區分設兩個實驗社區中心，由照顧經理擔任長期照護需求者和照顧體系間的橋樑，聯結服務。以建議服務與實際服務提供為指標評價管理的執行狀況；並利用兩個實驗社區中心各7次個案討論會的紀錄進行內容分析，探討照顧經理的訓練是否與其角色相符。結果：照顧管理服務和業務監控流程已建置完成，照顧經理共建議1511個服務，民眾只接受482 個，服務接受度31.9 %，跨專業照顧諮詢小組對照顧經理提供的指導以評估和服務協調或連結最多。結論：國內首項結合社政與衛政資源的社區式長期照護個案管理模式在實驗社區內已初步建立，民眾的接受度在學理和政策之意涵有待深入探討。
  Objectives: The purpose of this action research was to design, implement, and evaluate preliminary outcomes of a community-based care management model for long-term care. Methods: Chia-Yi City and San-Shia /Ing-Ger area of Taipei county were selected as a samples of the urban and rural community respectively, Care managers were recruited and trained while the experimental community centers were established in these two communities. The first outcome indicator was the number of suggested services and the number of actual services that care managers linked indicating implementation of care management. The second indicator was the major topics discussed in interdisciplinary case conferences indicating the extent of congruence between the focus of training and the expected role of care managers. Results: The services of care management were successfully delivered. A total of 1511 community - based services were suggested to the potential users by the care managers with only 482 service suggestions being accepted. The service utilization rate was 31.9 %. The 2 most discussed topics during case conferences were the assessment and coordination, and the linkage of services that were consistent with the role of care managers. Conclusions: For this action research, a care management model that integrated health and social services was established. The low acceptance of community-based services needs to be further explored.
• 197 - 208
• 10.6288/TJPH2004-23-03-04

• Link 原著 Original Article
• 建構長期照護體系先導計畫：實驗社區介入前的照護需求與自付費用Pilot Program for the Development of a Long-Term Care System: Demands and Out-Of-Pocket Expenses in Experimental Communities Prior to Intervention
• 吳淑瓊、莊坤洋、陳亮汝
  Shwu-Chong Wu, Kun-Yang Chuang, Liang-Ju Chen
• 社區照護 ； 長期照護 ； 醫療保健服務 ； 身心功能障礙者 ； 照顧需求
  community care ; long-term care ; medical and health services ; disable ; demand for services
• 目標：本研究的目的在分析社區身心功能障礙者的照顧需求，供社區照顧網絡建構與評估之參考。利用服務使用情形估算醫療保健、正式長期照護、和家庭照顧等三類服務的費用支出。方法：研究資料來自「建構長期照護體系先導計畫」嘉義與三鶯實驗社區實驗介入前的調查資料；兩社區共有43萬5千人，其中具有日常生活活動、工具性日常生活活動、或認知功能障礙者，即為本研究樣本；以面對面訪視收集服務使用和費用支出資料。結果：約三成的個案在過去一年使用住院和急診服務，約三分之二在一個月中，曾經看西醫門診。在長期照護方面， 72.1％完全由家人照顧，毫無外力協助；10.1％入住機構；僱用家庭監護工者14.1 %；6.6％使用社區正式服務。因此目前需要照顧的民眾除進機構，或僱用監護工外，很少有其他選擇。具有五項以上日常生活（activity of daily living, ADL）障礙或認知功能障礙，是個案入住機構或僱用監護工的重要決定因素。社區一個月自付醫療保健總經費合計兩百萬，其中七成用在西醫門診上，用於住院和急診不到8 %，可見全民健保對重大傷病的風險分攤作用；長期照護總費用約5,900 萬，家庭照顧者付出機會成本所佔比率最大，佔77 . 8 %，機構式服務佔10.0%，僱用家庭監護工佔11.8％。以上費用支出的估算並不包含全民健保給付、入住機構者的醫療保健支出、家庭次要照顧者薪資等；也並未包含照顧者負荷、因照顧而產生的照顧競爭、工作衝突等無形的負擔。結論：七成以上民眾的長期照護需求完全由家人照顧，入住機構和僱用家庭監護工為目前主要的外來協助，都在一成左右。社區式的照顧對民眾的幫助十分微少，是未來建構「在地老化」照顧體系的一大障礙。
  Objectives: To assess demand for services among the disabled in the community, and to provide baseline information for establishing a community care network for the disabled, Based on the current level of service utilization, this research intends to estimate the costs of medical care , formal long-term care, and family care. Methods: Data were collected in the baseline survey from two experimental communities (Chia-Yi City, and San-Yin area of Taipei County) selected for the Pilot Program for Long-Term Care Development. Eligibility for inclusion into the sample was having a disability in the activity of daily living, instrumental activity of daily living, or cognitive function. Out of the 435,000 residents in these two communities, those residents deemed eligible were interviewed face-to-face. Information regarding medical care, long term care, and family care were collected as the basis for cost estimates. Results: About one-third of respondents had been hospitalized in the past year. About 30% of respondents used emergency services. About two-thirds had had physician visits in the past month. As for long-term care, 72.1% depended solely on family members, 10.1% were institutionalized, 14.2% had hired an aid, and 6.6% used community-based care. Little alternative existed besides institutionalization and personal aid. The main determinants for institutionalization or hiring an aid were cognitive disability and ADL (5 items or more) disability. The total out-of-pocket medical expenses for the two communities over a month was about $ NT 2, 000, 000. Seventy percent was spent on physician visits, and less than 8% on hospitalization and emergency care. The cost of long-term care was estimated at 59 million, of which 77.8 % come from opportunity cost of family caregivers, 10% from institutional services, and 11.8% from personal aids. The cost estimation did not include reimbursement from National Health Insurance, the opportunity cost of a secondary caregiver, and caregiver burdens. Conclusions: Most of the long-term care is provided by family members, followed by institutionalization and personal aid. Community-based care only made up an insignificant percentage, representing a barrier before reaching the goal of “Aging in Place.”
• 209 - 220
• 10.6288/TJPH2004-23-03-05

• Link 原著 Original Article
• 給付標準的設定會引導民眾對社區式服務的利用嗎？－以居家服務為例Effects of Reimbursement Levels on the Use of Home Care Services
• 曾淑芬、莊坤洋、 陳正芬、葉乃禎、吳淑瓊
  Su-Fen Tzeng, Kun-Yang Chuang, Chen-Fen Chen, Nai-Chen Yeh, Swu-Chung Wu
• 給付標準 ； 服務利用 ； 居家服務
  reimbursement level ; utilization ; home care services
• 目標：為了解社區失能者在不同的居家服務給付方案下，個案實際使用服務的情形與差異性，以及影響服務使用的相關因素。方法：本研究選取六家受台北市政府委託辦理居家服務之機構，並以該六家機構所收案並提供服務的對象為研究樣本，樣本資料係來自服務提供機構的個案記錄等相關資料，收集自89年1月至90年3月期間，各單位新開個案一個月內使用居家服務之相關資料，進行分析，總計取得樣本數為454人，經刪除資料不適用個案後，得有效樣本數為 440 人。結果：（l）將近三分之二的個案其一個月服務使用時數都集中於16小時（63.4%），其中一般戶月服務使用時數為16小時之比例更高達86.1%，而低收入戶在該項的比率則僅有13.8％。（2）低收入戶個案的月使用時數超過16小時以上者佔70 %，且使用的最高時數為96小時（佔13.8%），而非低收入戶月服務使用時數超過16 小時以上者僅佔7.8％。（3）邏吉斯複迥歸分析結果，在控制相關因素之後，低收入戶高時數服務使用（大於16小時）的可能性比非低收入戶多58倍（危險勝算比為57.8），完全依賴個案的高時數服務使用可能性則比輕度依賴者高出6倍（危險勝算比約為5.9）。而個案年齡則與月服務使用時數成正比，未婚者比已婚或同居者有較多的機會使用高時數服務（危險勝算比則為2.8），家庭照顧資源越少者其使用高時數服務的可能性越高。結論：由於政府給付上限設定的不同，使低收入戶與非低收入戶兩類不同身分類別的個案，在居家服務的使用也有明顯的差異，顯示政府給付標準的設定對民眾服務的使用有極大的主導作用，因此，未來在進行長期照護保險的現劃時，有關支付制度的設計，應同時考量民眾的付費能力與實際的照顧需要，以避免服務利用多集中於低收入戶的現象，並能更適當合理的運用照護資源。
  Objectives: To investigate the use of home care services and the possible effects of reimbursement levels and other factors associated with the use of services. Methods: Six home care services providers, all under contractual agreement with the City of Taipei to provide services, were selected. Data (n = 454), in the form of documents and clients records, was collected from the providers from January 2000 to March 2001. After the elimination of inappropriate data, the final number included for analysis was 440. Results: (l) About 63.4% of the cases used 16 hours of services a month. Among the 16-hour users, 13.8 % were from low-income households. (2) Among the low-income users, 70% used more than 16 hours per month. Some (13.8 %) used as many as 96 hours a month. For cases not in the low-income group, only 7. 8 % used more than 16 hours. (3) Logistic regression showed that, after controlling for other variables, the low-income (OR= 50.8), severely disabled (OR=7.6), and the unmarried (OR=15.9) were more likely than their counterparts to use more than 16 hours of services per month. Furthermore, being younger, and having more family care resources were associated with using fewer hours. Conclusions: Level of reimbursement has significant impacts on the use of services, as indicated by the wide disparity in services hours used between low-income users and others. In planning for long-term care insurance, in order to avoid the skewing of needs for the use of services towards the low-income group, the design of reimbursement schemes should take into account both the ability to pay and also their level.
• 221 - 234
• 10.6288/TJPH2004-23-03-06

• Link 原著 Original Article
• 中風病人具身體功能障礙者出院準備服務之執行評估：病人的角度Evaluation of Discharge Planning Services for Stroke Patients with Disabilities: Patient Perspectives
• 蔡宗學、莊坤洋、戴玉慈、曾淑芬、吳淑瓊
  Tsung-Hsueh Tsai, Kun-Yang Chuang, Yu-Tzu Dai, Su-Fen Tzeng, Shwu-Chong Wu
• 出院準備服務 ； 連續性照護 ； 病人角度
  discharge planning ; continuum care ; patient perspective
• 目標：針對醫院為有長期照護需要病人安排的出院準備服務，詢問病人對醫院提供出院準備服務的感受，分析接受出院準備服務狀況及其影響因子。方法：調查 489位由臺北縣市七家醫院中風出院有後續照護需要病患，了解病人對出院準備服務包括告知出院時間、出院時機、討論如何照護、提供衛生教育、協助後續長期照護安排、出院後持續追蹤等六項指標之感受，並以迴歸分析探討影響因子。結果：病人感受醫院人員大部分或很詳細討論如何照護與提供衛生教育皆有七成以上，但有77.3％的病患認為醫院並無協助後續的長期照護安排，有58.5％的病患在出院前二天以上被通知要出院，有68.1%的病患覺得出院時間剛好，而有94.1％病患認為醫院並無持續追蹤他們。迴歸分析中，醫院別和身體功能障礙是顯著的重要變項，其他醫院相對於乙醫院的勝算比都小於1，中、重度失能相對於輕度失能的勝算比皆大於l。結論：病患感受的出院準備服務品質不佳，且不同醫院的服務有差異，並可能選擇病患，針對功能障礙不同的病患提供不同的出院準備服務。
  Objectives: To explore patients ' perception of discharge planning and uncover the factors associated with it. Methods: The study sample were 489 stroke patients discharged from seven different hospitals in Taipei. To survey these patients' perceptions of six important indicators including patients being informed before the discharge date, premature or retardant time being discharged, discussion of post-discharge care with patients or their caregivers, providing health education to patients or their caregivers, referral to post-discharged long-term care services, following discharged patients up. Results: More than 70.0% of patients considered the hospital staff had discussed post-discharge care with them carefully or perceived they had been provided with health education. More than three-fourth of patients believed that hospitals had inadequately handled the referral of post-discharged long-term care services. There were 58.5% patients informed two days before. As to the timing of discharge, 68.l % of patients thought it was suitable. The follow-up aspect of our study was quite uniform 94.1% of patients perceived no follow-up. Analyzed factors associated with perception of each service, hospital and physical function disability were found to be significant factors after controlling for other variables. The odds ratio of hospitals over the B hospital was less than one and reached a significant level that means the service provided by B hospital was more acceptable than for the other hospitals. In the facet of physical function disability, the odds ratios of moderate disability over minor disability and severe disability over minor disability were larger than one and significant. Conclusions: The result showed patients' pessimistic perception concerning the quality of discharge planning. The discharged patients from different hospitals have dissimilar perceptions of discharge planning services provided by hospitals. The more severe the disability, the stronger the perception of having discharge planning services being provide by the hospital. Hospitals may choose patients and provide the different discharge planning service according to the different disability levels.
• 235 - 248
• 10.6288/TJPH2004-23-03-07

• Link 實務 Public Health Practice
• 建構長期照護體系先導計畫－理念與實踐A Pilot Program for the Development of Long-Term Care System - Concepts and Practices
• 吳淑瓊、戴玉慈、莊坤洋、張媚、呂寶靜、曹愛蘭、王正、 陳正芬
  Shwu-Chong Wu, Yu-Tzu Dai, Kun-Yang Chuang, Mei Chang, Pau-Ching Lu, Ai-Lan Tsao, Cheng G. Wang, Chen-Fen Chen
• 長期照護體系 ； 資源發展 ； 財務支持 ； 照顧管理 ； 實驗社區
  long-term care system ; resource development ; financial support ; care management ; experimental communities
• 目標：本文說明建構長期照護體系先導計畫的理念、計畫策略、和初步執行結果。該計畫希望能以可負擔的居家和社區式服務協助身心功能障礙者，以達到「在地老化」的目標。方法：在 2000 年行政院核定「建構長期照護體系先導計畫」三年計畫。該計畫選擇嘉義市和台北縣三鶯為實驗社區，於2001年10月分別在兩社區成立社區中心，每一中心配置4-5位照顧經理，一位主任，和一位行政專員，負責推展照顧管理服務、及督導新型服務模式的發展。從2002年1月起，社區開始提供各項居家和社區式服務。結果：到2002年7月為止，照顧經理總共替 1031位個案擬定照顧計畫，其中，469位個案依據照顧計畫接受服務。除補助兩社區新型服務的開辦費（約1400萬元）外，兩社區補助民眾接受服務的費用共約474萬元。結論，初步結果顯示服務提供者有發展居家和社區式服務的意願，但是民眾對此服務並不熟悉，可能造成初始之低使用率。在計畫的補助標準和照顧管理制度的設計下，提供居家和社區式服務的財務負擔並不如預期沈重，但須更長的觀察，才能驗證上述之成果。
  Objectives: This report described the conceptual framework, strategic planning and implementation, and preliminary results of the Pilot Program for the Development of Long-Term Care System. The program aimed to achieve “Aging in Place” by making home and community-based services affordable to the disabled. Methods: In the year 2000, the Executive Yuan approved a three-year project, the Pilot Program for the Development of Long-Term Care. Chia-Yi City, and the San-Yin Townships of Taipei County were selected as experimental communities. In October, 2001, a community center was established in each experimental community. Personnel included 4-5 care managers, 1 director, and 1 administrative assistant. The main tasks of the center were to carry out care management scheme, and to supervise new long-term care service models being implemented in the communities. Starting in February 2002, home and community based services became available to the disabled in the communities. Results: By the end of July 2002, care managers had drawn up care plans for l,031 disabled residents. Among them, 469 people had used home or community-based services according to a care plan. Subsidies to service providers were at about 14 million NT dollars. Reimbursement for services totaled about 4.74 million NT dollars . Conclusions: Initial results had shown that service providers were willing to invest in developing resources for home and community based services. Unfamiliarity with the services had probably initially led to lower than expected level of utilization. Under the current care management and service reimbursement schemes, financial burden of providing home and community based services was not as heavy as anticipated. However, continual observation 15 needed to confirm initial findings.
• 249 - 258
• 10.6288/TJPH2004-23-03-08