2020-01-012024-05-13https://scholars.lib.ntu.edu.tw/handle/123456789/654076摘要：臺灣實施全民健康保險後，民眾的就醫可近性大幅提升，顯著縮減不同族群或區域間的健康差異，加上尚可接受的整體費用控制，臺灣健保在國際間享有讚譽。然而，跟許多歐美國家一樣，臺灣過去的醫療體系發展，過度偏向專科化，使得醫療服務缺乏基層醫療或家庭醫師的照護與轉診，因而呈現醫療片段化的現象，可能造成重複檢驗檢查與用藥的浪費，也損及醫療品質。健保署於2013年開始實施雲端藥歷計畫，提供跨醫療院所的即時性病患用藥資訊分享平臺，成為提升跨院所醫療合作的基礎，唯目前雲端藥歷的使用與成效尚待評估，而健保淑提供給民眾的健康存摺，其使用率也有待提升。 本計畫旨在發展一套創新的服務模式，提升多重用藥病患的照護協調性，藉由彙整與善用現存的全民健保醫療資訊雲端系統以及民眾的健康存摺的資訊，由研究團隊與建保署合作，主動提供病患所需的個人化用藥與醫療保健資訊，滿足具有複雜醫療需求族群的醫療照護需求，提升民眾接受照護的協調性與連續性；另外也與醫療院所合作，由個管師介入強力衛教，鼓勵病患參與自己的健康管理，提升醫療服務的品質與效率。在發展與提供健康導護服務的同時，本計畫將進行嚴謹的成效評估，採用實驗介入的研究設計，以瞭解本計畫為病人所帶來的效益，並持續精進健康導護服務模式，以期可以推廣到全國醫療院所。<br> Abstract: The implementation of National Health Insurance (NHI) in Taiwan has improved people’s accessibility to care and reduced the health disparity among sub-groups and geographic areas. The achievement of the universal health insurance is well recognized around the globe. However, similar to many industrialized countries, due to the prevailing development of medical sub-specialties and the lack of referral system, fragmented care and duplicated medication and medical procedures has been existing in Taiwan’s health care system. The NHI administration has introduced a medication (and healthcare information) sharing platform in 2013 which provided almost real-time health care information of all the NHI enrollees and can be accessed by health care providers nationwide. However, the effects of the healthcare information sharing platform need to be evaluated, and the usage of individual’s NHI health records (i.e. Health Bank) is limited and needs to be promoted. The objectives of this project is to develop an innovative health service model to promote coordinated care and to evaluate its effectiveness. This project will enhance the roll of case-management for patients with chronic conditions. The major activities of the care-coordination improvement are to acquire and summarize patient’s health information from hospital’s medical record, NHI health information sharing platform and patient’s NHI health bank, and to provide individualized health information and health education. Through the services of improved care- coordination, patients may receive better coordinated care and more actively engaged in their own health management, which will lead to improved care quality and efficiency. This project will conduct a rigorous study to evaluate the effectiveness of the care coordinator model with an experimental study design, and refine the service model along with the project.門診服務照護協調性照護連續性介入評估primary carecare coordinationcare continuityinterventionevaluation