2024-05-182024-05-18https://scholars.lib.ntu.edu.tw/handle/123456789/715788National Taiwan University Hospital (NTUH) is the leading medical center in Taiwan. To implement the National Health Insurance (NHI) referral and levels of care policy, NTUH has launched a 5-year program for NTUH Healthcare Networks, named “Patient-centered Seamless Transition and Referral System (P-STARs)” since September 2018, which aims to build up better NTUH healthcare networks. NTUH invites healthcare providers in and nearby Greater Taipei area to join the P-STARs. We shall work together and share common visions in order to build up a patient-centered healthcare network through information exchange, to make medical referrals by vertical integration of healthcare providers, and to successfully maximize the quality of referrals within our healthcare alliance organizations. Through the alliance healthcare networks and the promotion of “Choosing Wisely”, NTUH anticipates that P-STARs program would provide a seamless healthcare environment, promote better quality of care, and strengthen the effective referral of healthcare resources between different levels of care. With the increasing demand for establishing the referral system and transition care, Referral Management Center (RMC) of NTUH was founded on June 10, 2019. RMC has four divisions: Administrative Affairs, Information Technology, Education and Training, and Care Coordination. RMC aims to carry out a successful P-STARs program. Through the systems-based healthcare networks, NTUH aims to deliver better referrals between levels of care, to establish case management and integrated care clinics, to make horizontal and vertical integration of medical resources; to do care management for higher medical resources utilizing patients and end of life patients; to the general public by promoting “Choosing Wisely” and understanding the importance of finding a family doctor as well as stronger personal health, diseases, and knowledge of aging, to provide a better healthcare environment, quality of care and the effectiveness of healthcare resources.為支持國家分級醫療政策，健全臺大基層醫療體系及健康照護網，臺大醫院於2018年9月啟動五年期的「臺大醫院醫療體系星月計畫」。本院結合理念相符、關係友好的大臺北地區院所，以病人為中心、家庭為單位、社區為基礎，逐步建構資訊互通、轉銜照護、垂直整合、知識交流的分級醫療體系。冀望透過以體系為基礎的醫療分工與聰明就醫運動，進行健康照護體系進行垂直整合與銜接照護，以提供民眾更好的就醫環境與醫療品質，並促使醫療資源之有效運用。 由於垂直轉銜照護事務需求日益增加，本院於2019年6月10日成立分級醫療暨轉銜照護管理中心。中心下設有四個功能小組：行政管理組、資訊管理組、教育訓練組與照護協調組，共同執行五年期的星月計畫相關事務。 未來冀望透過以健康照護體系為基礎的醫療分工，進行多重慢病整合門診與垂直整合、銜接照護；高醫療利用及末期病人個案管理；促進民眾聰明就醫運動，尋找合適的家庭責任醫師，提高並強化健康識能、疾病識能及老化識能，以提供民眾更好的就醫環境與醫療品質，並促使醫療資源之有效運用。