A Reliable Medical Team for Dementia Care - The Experience Sharing of Disease Specific Care – Dementia Certification Program

Abstract

<p>臺灣即將邁入超高齡社會，罹患失智症的人口數快速上升。失智症合併精神行為症狀及其導致的失能經常帶給照顧者極大的負荷，相關的醫療與長期照護議題至關重要。為了提升失智症照護品質，本機構參與醫策會所主辦失智症照護品質認證。準備認證期間，雖面臨許多挑戰，但團隊合力一一克服，最關鍵的因素是跨專業共同合作及良好溝通機制。依照醫策會所提供照護認證指引，本機構組建全面照護的全人醫療團隊。「全家」照護藉由醫病共享決策，給予照顧者必要的支持和諮詢，「全隊」照護由各種醫療專業職類共同合作，透過個案管理，提供極輕度以至末期失智症的「全程」照護，「全社區」照護則是強化團隊與公部門和在地失智症據點的聯繫網絡。確立標準照護流程與持續監測品質指標是認證後重要收穫，同時也彰顯了疾病認證的價值，團隊以此經驗分享予所有努力提升失智症照護品質的專業人員。</p> <p> </p><p>Taiwan is on the verge of becoming a super-aged society, with the number of people suffering from dementia rapidly increasing. Disability, behavioral and psychological symptoms caused by dementia impose a heavy burden on caregivers. The medical and long-term care of dementia is crucial in Taiwan. To optimize the quality of care, our hospital participated in the disease specific care – dementia certification program. During the process of certification, interdisciplinary collaboration is the most important. Following the guidelines from the Joint Commission of Taiwan, we established a team that features extensive holistic dementia care. We care “whole family”, providing necessary support to caregivers of patients with dementia, and counseling through shared decision making. We offer “whole team” care from different healthcare professionals. Through case management, patients’ conditions are followed regularly from the very mild stage to the end stage as “whole course” care. We built a strong connection with public agencies and local dementia care stations to create a “whole community” network. The establishment of consistent care processes and indicators to assess the quality of care marks the value of care certification program. The experience is shared with all professionals who exert efforts to improve dementia care.</p> <p> </p>