對現況的建議

第五章討論

第三節對現況的建議

臺灣發展遲緩兒童早期療育的資深實務工作者（林美瑗，2010）認為：「早期療育應該最早期介入的對象是『家長』而不僅是兒童本人，也唯有靠家長

『早期明瞭』的覺悟和行動，才有機會和孩子的發展黃金期賽跑」。臺灣近幾年之研究指出，參與親職教育方案之家長教養能力顯著高於僅接受親職資料備索者（蔡淑桂，2009），而若家長共同參與並執行居家療育計畫，對促進兒童之各領域發展與功能性技巧，及降低照顧者在日常活動的協助量，都有正向影響（唐美華、陳君薇、蔡森蔚、陳昭惠、林巾凱，2010）。由此可見，家長本身在發展遲緩或身心障礙兒童之療育進展的部分扮演相當重要的角色。

「以家庭為中心的服務」已經成為各國早期療育及兒童復健努力的方向，

然而，本研究結果顯示臺北地區兒童復健服務在「提供一般資訊」及「提供具體資訊」向度相當不足，而過去國外相關研究也均有類似的現象(Arnadottir

& Egilson, 2012; Dickens, et al., 2011; Jeglinsky, et al., 2012; Schreiber, et al., 2011)，另外，治療師賦能於家長的行為也有待加強。因此研究者參考國外學者之建議，針對早期療育政策、健保給付制度、臨床服務制度及早期療育督考或評鑑分別提出以下建議：

1.早期療育政策面

芬蘭學者(Jeglinsky, et al., 2012)指出：「only when the need for an

individually tailored and family-centred approach is acknowledged by the health decision makers as well, can the conditions for family-centredness be secured.」。因此應從最根本的法源建立「以家庭為中心的服務」，即兒童及少年福利與權益保障法，該法之施行細則第8 條定義早期療育「是指由社會福利、衛生、教

需求，提供必要之治療、教育、諮詢、轉介、安置與其他服務及照顧。」建議應在施行細則當中加入「以家庭為中心的服務」的辭彙及其定義，尤其是

「提供一般資訊」及「提供具體資訊」向度的內容，並由相關主管機關明確擬定配套行政措施，且編列足夠的預算。

2.健保給付制度面

現行全民健康保險醫療費用支付標準（行政院衛生署中央健康保險局，

2012）之第二部第二章第四節復健治療當中，以職能治療診療項目之複雜治療為例：「實施本項須符合於下列適應症及其項目規定：兒童中樞神經系統疾患(含外傷造成及罕見疾病)：(1)限從出生至滿十二歲以前。(2)治療項目三項(含) 以上，合計治療時間三十分鐘以上。」為了使服務不僅著眼於兒童，且強化治療師賦能於家長的服務，建議將(2)之描述修改為：「治療項目三項(含)以上，

須包含兒童直接治療及家長諮詢，合計時間三十分鐘以上」。或是將「家長諮詢」獨立為一兒童復健治療的給付項目，此一建議已於2011 年 4 月 25 日立法院之社會福利及衛生環境委員會會議－「我國『早期療育』政策之發展、

現況與問題」中，由陳瑩立委提出，衛生署副署長江宏哲也承諾會與健保局進行研議（立法院，2011）。

另外，目前健保支付兒童復健治療為論量計酬，在此財務誘因之下，兒童復健單位可能提供較多的團體治療，或是增加每個團體中的兒童數量。然而，本研究結果顯示，相較於團體治療，個別治療能讓家長感受較高程度之

「以家庭為中心的服務」，因此，研究者提出以下想法：衛生主管機關，如中央健保局及地方衛生局，或許可參考MPOC-20 臺灣版或 CanChild 網站 (CanChild, 2012a)，發展評估兒童復健單位「以家庭為中心的服務」之檢核表，

以此檢核表的分數當作各單位每日每位治療師申報兒童復健治療人次上限的依據，亦即服務越能符合以家庭為中心之單位，才能申報越多的治療人次，

藉此提供新的財務誘因，鼓勵各兒童復健單位強化以家庭為中心的服務。

3.臨床服務制度面

目前每節兒童復健治療的時間多為30 分鐘至 50 分鐘，不論是個別治療或是團體治療，治療師皆須有足夠的時間來提供資訊給家長、賦能於家長，

就短期而言，研究者做出以下建議(可適用於個別治療及團體治療，而在團體治療的部份，特別需要整個部門的治療師參考、並且共同研擬調整策略)：

(1) 治療師可視情況增加家長衛教諮詢的時間(以 30 分鐘的治療為例)，

如：直接治療15 分鐘、家長諮詢 15 分鐘。

(2) 治療師可視情況調整治療時段的對象，如：每 6 次的治療時段當中，

至少1 次請家長單獨前來，與家長做詳細之討論與諮詢。

(3) 與家長溝通「以家庭為中心」的理念，鼓勵家長成為協同治療者：

提供居家治療活動及教養技巧方面的建議給家長、將治療延伸至兒童每日的生活，以增進療效，並且依照個別家庭之教育程度、環境和需求與其討論執行居家治療活動的可行性，並給予心理支持。

4.兒童復健單位之早期療育督考或評鑑

臺灣地區1996 年早期療育服務供需的研究指出，有六成以上的家長希望能夠有人指導如何教育孩子、提供相關書籍刊物（王天苗，1996），相隔 16 年之後，本研究結果仍顯示兒童復健服務在「提供一般資訊」及「提供具體資訊」向度相當不足，因此除了健保支付制度，早期療育督考或評鑑也可以扮演監督的角色。加拿大學者(Darrah, Wiart, Magill-Evans, Ray, & Andersen, 2012)指出：「將『以家庭為中心』的價值觀融入該單位的服務理念(philosophy) 及宗旨(mission statements)，為該單位承諾提供『以家庭為中心』之相當重要的指標，更重要的是，兒童復健單位需要與家庭共同設計『以家庭為中心』

之服務架構，且明確定出標準化的服務流程」。早期療育評鑑內容可參考圖六

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在文檔中家長感受兒童復健服務過程之「以家庭為中心」的程度及其影響因子：以臺北地區為例 (頁 83-118)

第五章 討論

第三節 對現況的建議