應用個案管理於控制腦中風病患照護品質及成本效益之成效探討
中文摘要
論文名稱 : 應用以醫院為基礎之個案管理於社區精神分裂病病人之照護成效探討
研究所名稱 : 臺北醫學大學護理學研究所
研究生姓名 : 何淑鳳
畢業時間 : 九十二年度第二學期
指導教授 : 盧美秀 臺北醫學大學護理學研究所教授
精神醫療模式的發展，以社區為導向已成為治療精神病患之主流。目前台灣地區精神科病床不足，社區精神復健機 構普及性及使用率也不高。整個醫療服務體系並未健全，個案管理照護模式在社區中應能發揮連續性的完整照護服 務。本研究旨在探討應用以醫院為基礎之個案管理對於出院後之精神分裂症病患在精神症狀、社會功能、規則門診 及服藥狀況、再住院率、服務滿意度及主要照顧者負荷等指標之成效。
本研究採類實驗設計法，於某區域專科教學醫院立意取樣，研究期自 2003 年 10 月至 2004 年 5 月取得急性病房符合 收案條件之出院個案。實驗組由社區護理人員共五位輪流收案，收案後依據個案需求評估個案管理照護項目及目標，並以標準步驟訪視及電話追蹤共三個月。管理照護項目包括：症狀管理、藥物管理、日常生活技能輔導、家屬支 持、社會福利資源轉介等。對照組為同期間出院僅接受門診治療及電話追蹤照護之病患。研究資料之收集包括兩組 個案之人口學基本資料及疾病屬性；由病歷及以相同問卷訪談，進行雙組精神症狀、社會功能、照顧者負荷前後測 差異分析及返診規則性、服藥規則性、再住院率、服務滿意度之後測差異分析。所得資料以 SPSS PC 11.0 及 SAS 10 .0 版套裝軟體處理，統計方法包括平均數、百分比、獨立樣本 t- 檢定、卡方檢定、 GEES (Generalized Estimating Eq uations) 迴歸模式等。
本研究樣本實驗組 30 名及對照組 33 名，實驗組及對照組個案之基本資料及疾病屬性在統計上並無顯著差異。研究 結果顯示 : 實施個案管理後實驗組與對照組個案之社會功能具統計上顯著差異 ( p <.001) ，主要照顧者對於能獲得適 當之醫療照顧較具信心 (p <.001) 。而兩組個案之精神症狀 (p =.316) 、照顧者負荷 (p =.459) 、返診規則性 ( p =.84) 、 服藥規則性 (p =.70 ) 、再住院率 (p =.59) 及服務滿意度 (p =.543) 均無統計上顯著差異。結論為本研究以醫院為基礎 之個案管理照護模式，可提昇個案之社會功能，促進個案之生活品質；使主要照顧者對獲得適當之醫療照顧有信心，值得推展。
關鍵詞：以醫院為基礎之個案管理、社區精神分裂病病人、照護成效Application of case management on patients with stroke : Examining quality of care and cost benefit
英文摘要
The purpose of this study was to investigate the application ofcase management in the frequency of complication, cognition of self-care, satisfaction on health care, length of stays, medical cost, and related factors on the length of stays and medical cost in hospitalization for the cerebrovascular accident(CVA) patients. The Quasi-experimental design was used in this study. Based on the hospitalization order and the study inclusion criterion, the total sample consisted of 114 CVA patients. The subjects were divided into two groups, 57 subjects in each group. The subjects in the experimental group received case management method and the subjects in the control received the routine care method.
Content validity, Cronbach''s alpha, and Kappa were performed to examine the validity and reliability of the instruments used i
this study. Using Cronbach''s alpha method, the reliability coefficients were 0.75 for the evaluation tool of self-
cognition, and 0.88 for the satisfactory questionnaire. Kappa method was used for the agreement among the researchers and coefficient was 0.86. Data collection was done by using the demographic data sheet, the evaluation tool of self-cognition,
the satisfactory questionnaire, and the patient''s chart. Data also were collected from the center of research institutuions.
The pre-test was done by researcher within 24 hours after
patient''s hospitalization, and the post-test was done on the day of patient''s discharge.Data were analyzed by using the chi- square test, t-test, pair t-test, Mc Nemar''s test, ANOVA and multiple regression test. The results indicated that the
frequency of urinary tract infection on experimental group was significantly less. The experimental group was significantly
higher in the cognition of self-care and patient''s satisfaction on medical health care.The experimental group was significantly less in the average length of stays and medical cost. There was no significant difference on Activities of Daily Living Dependent Index, Coma Scale and the types of placement on the
patient''s dischargeday. The study results also showed that Case management and variance causes, pnumonia, coma scale index, and diagnosis could predict the length of stays.The toatl explained sources of variation was 61%. Case management and
variancecauses, pneumonia and coma scale index could predict the medical cost. Base on the study results, it was concluded that the implication of casemanagement method can effectively control quality of care, length of stays andmedical cost in CVA
patients. In addition, during the change of insurance paymentpolicy, the findings would provide to nursing administrators as on managing quality and cost.
