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
The Effectiveness of Applying Hospital-based Case Management for Schizophrenic Patients in Community
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 Equations) 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
英文摘要 Abstract
Title of Thesis: The Effectiveness of Applying Hospital-based Case Management for Schizophrenic Patients in Community
Institution:Graduate Institute of Nursing, Taipei Medical University Author: Ho, Shu-Feng
Thesis directed by: Lu, Meei-Shiow, Professor
The development of the community mental health service had become the mainstream of psychiatric patient treatment. In Taiwan, the bed capacities for psychiatric patients are short, the community rehabilitation institutes and the utility rate are also
insufficient. In other word, psychiatric rehabilitation services system has not been well established. Therefore, the continuing care of case management should be able to provide comprehensive care model in the community. The purpose of this study is to explore the effectiveness of applying the hospital-base case management for
discharged schizophrenic patients, including the following dimensions: psychiatric symptom, social function, burden of major care giver, regular outpatient visits, drug compliance, readmission rate, and the client satisfaction on service providing.
The design of the study was quasi-experimental using a purposing sampling in a district teaching hospital. During the period between October, 2003 and May, 2004, the discharged patients who fit the criteria of this study were assigned to the study.
Subjects in experimental group were assessed by five case managers (nurses) for goal and contents of care. The standard operation procedure was used in psychiatric home visit and phone call for three months. The case management components include symptom management, medication management, daily life skill training, family support and Social welfare support. While the control group subjects accepted usual out-patient and phone call follow up at the same period after discharged. The
demographic data and characteristic of diseases for all subjects were collected before study. The data of psychiatric symptom, social function, and burden of major
caregiver were using standardized questionnaire to evaluate for pre-test and post-test comparison and the regular outpatient visits, drug compliance, readmission rate, client satisfaction were collected from patient chart and questionnaire after implementation for post-test comparison. All the data are processed by using SPSS version 11 and SAS version 8.0. Statistic methods include mean, Percentage, independent t-test, Chi-square test and Generalized Estimating Equations (GEEs) to compare the difference between two groups after implemented the case management model.
There were 30 subjects in experimental group and 33 subjects in control Group. No
statistic significant differences were showed on demographics and disease
characteristics between experimental group and control group. The result of this study reveals statistic significant difference on social function of clients between
experimental group and control group (p<.001); and major care giver had more confident in psychiatric medical care(p<.001). However, no significant difference among Symptom (p=.316), burden of major care giver (p=.459), regular outpatient visits (p=.84), drug compliance (p=.70), readmission rate (p=.59), and client satisfaction (p=.543) on case management.
Conclusion: The finding of this study indicated that Hospital-based case management model can improve social function of clients, to enhance their quality of life and the major care giver has more confident in psychiatric medical care. Therefore, extension of this model is highly recommended.
Key word: Hospital-based Case Management, Schizophrenic Patients in Community, Effectiveness of health care
