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 Home Minister & Policy
Minister & Policy
 Chang-Hua County integrated long-term care strategies for 2006-2007
A.The strategies is based on the following policy: Department of Health, The Executive Yuan 0942801851 which passed on December 9th 2005
B. The strategies is implemented between January 2006 to December 31th 2007
C. Overview
●Backgrounds
In 2005, a pilot program was initiated in Department of Health, The Executive Yuan Changhua hospital, Changhua Christian Hospital, Show Chwan Hospital to provide integrated health care services for stoke patients in order to minimize the post-discharge burden after patients become fully or partially paralyzed. 52 home care nurses were recruited, and currently total of 500 health providers are in the service.
Studies had conducted in order to assess providers' quality and provide understanding of patients and their family's needs. The survey showed that 96% of patients and their family satisfied with the proposed integrated service. They most satisfied with doctor visits and instruction of medication use, and followed by rehabilitation services and nutrition education. Survey indicated that rehabilitation service is the most needed service for patients and followed by doctor visits service.
●Evaluations
- Ratio of paralyzed population
Data recorded by the end of July of 2005 has showed that there are 142034 people, 10.8% of the total population, age 65 and older in Chung-hua county. Among them, about 12783 elders who cannot take care themselves, about 8949 elders who need basic home care, about 3834 elders who need institutional or nursing home care. Based on activities of daily living (ADL) disable definition, for people age 20 and older, there are 16968 people who are 1 ADL disability, 9105 people who are 5 ADL disability. According to 2005 survey on disable population, about 96.7% of physical-psychological impairment can be categorized into 7 types, 42% are physical impairment (1/3 are elders, 2/3 between age 15-64). There is an association between type of physical-psychological impairment and age, and residency.
- Care resource and supply
2-1.Estimated 3834 elders need some form of institutional care. So far, there are total of 50 nursing homes and assistant living institutions, which equipped with 2394 beds. Additional of 2006 beds are in plan, with that, we will have 4400 beds for elderly cares.
2-2.Estimated 8949 elders require community-based care, there are 13 home care institutions, 34 nursing staffs, 19 rehabilitation institutions, 217 physical and occupational therapists, 9 hospitals which can provide discharged services, 3 hospitals and 52 home care nurses are in pilot program of integrated long-term care for stroke patients, 514 health care providers, 1550 doctors, 1805 beds for long-term care patients, 6 hospitals are qualified to provide care for physical-psychological impairment patients, 2 consulting centers, 1 local agency which provide home visit and training. In addition, there are 305 health care providers and 74 supervisors within 7 areas home care support centers, 5 day-care centers and 10 centers which provide meal service for elders.
- Human resource
The Chunghua long-term care center was established in 2003, and since then, the center has collaborated closely with social service agencies. The center currently has 3 care managers who are responsible for long-term care management and stroke patients integrated care services, and 1 social worker, who provides consulting service, and spends 4 hours per week evaluating the resources for caring brain injury patients. The center also plans to recruit 2 staffs with nursing backgrounds to screen the applications for hiring caregiver from overseas.
●Goals
- Provide hospital discharge services for 800-1000 stroke patients
- Provide post-discharge communities-base care for 800-1000 stroke patients
- Provide continuous 2-month communities-base rehabilitation service for 10% of stroke patients.
- Provide resources for 150 families that have paralyzed patients.
●Details and Methods
- Provide integrated health care for stroke patients. The service will be available for 800 patients in year 2006 and 1000 patients in year 2007.
Steps:
- Stroke patients admitted to Department of Health, The Executive Yuan Changhua hospital, Changhua Christian Hospital, Show Chwan Hospital, and Changhua Christian Hospital Er-Lin Branch in the same calendar year will be filed in the long-term care center.
- Improve discharge services for stroke patients within the 4 hospitals mentioned above. Periodically contact the hospital administrative staffs, and the social service worker from our center will periodically visit Changhua Christian Hospital to evaluate the social service.
- The care manager in our center will assign patients to different management centers based on his/hers residency. Each patient will be followed and receive individual care in each management center for 6 months, and for patients who are not assigned to any management centers, the care manager will provide care on the case-by-case basis.
- After 6 months follow up, patients will continue receiving care through center care managers and communities-base service.
- Host conferences and training for service providers for quality assurance.
- Set-up management center in Er-Lin and Yuan-Lin Townships, provide services for nearby patients.
- The care managers will evaluate this proposed strategies to ensure service quality.
- Analyze the data from monitoring and out patient services for future policy formation.
- Long-term community-based rehabilitation services
Steps:
- Each stroke patient will be categorized as Brunnstrom type I to type IV based on doctor's diagnosis. For patients who need rehabilitation, he/she will be transferred to long-term care center via hospital discharged service, and will receive rehabilitation service from hospitals where the patient received treatment or nearby hospitals.
- Work with physical-psychological professionals to provide consulting, evaluation, and training services.
- Work with social affair agencies to provide individual case consultation and evaluate patients' living environments
- Provide once a week physical, occupational, or speech therapies based on patients' need.
- Provide shuttle services for rural residents and rehabilitation center.
- Work with social affair administrations to provide shuttle service for stroke patients.
- Home care center will provide aids for patients who live alone.
- Host a get-together party for stroke patients' family members every 4 months, teach simple rehabilitation techniques for family members and caregivers, and provide support among family members.
- Periodically follow rehabilitation progress for patients
- Provide 150 caregivers temporary burden reduce/relieve service
- Temporary transfer disabled patients to living-assistant institutions to reduce family member burden.
- Formulate guidelines to apply for temporary burden reduce/relieve.
- Health policy and social service agency (local health clinics, center care managers, and social family service agencies) will evaluate cases and provide necessary relieve services.
- Home care services for patients living in rural areas
- Local home care service agency and care hospitals can provide the most convenient and fast services.
- Long-term care center will handle these patients case-by-case and provide local consultations, or transfer service in order to minimize patients and their caregivers traveling time.
- Train local home care service centers to ensure service quality and its utilities
- Improve long-term care services for disabled patients and their family member who are difficult to follow and monitor
- Press-conference to advocate hospital discharged services within Chang-Hua County.
- Work with hospitals to formulate post-discharge care plans
- For patients who are difficult to follow by the care hospitals, they can be transferred to long-term care center to receive care.
- Provide multiple care options such as caregivers from overseas for disabled patients and families
- Set up information resources, and inter-net center
- Routine evaluation to ensure health care quality.
- Periodical have meetings to discuss care policies and review cases.
- Collaborate with policies from Department of Health, Executive Yuan, and modify this integrated care strategies.
●Strategy Evaluations
- Whether stroke patients receive a integrated discharge services from hospitals
- The ratio of stroke patients who participate and complete communities-based care services.
- The ratio of stroke patients who continue to receive out patient services and take medication within 3 month of discharge.
- The ratio of stroke patients who have another stroke within one year period of time
- The ratio of stroke patients who continuously receive rehabilitation 6. Periodically have update meetings
●Expected Results
- For the stroke patients admitted in the three hospitals, they should be treated case-by-case and each case will receive discharge health care from the hospital and later will receive communities-base health care provided by long-term care center.
- Provide adequate discharge health care services for stroke patients in order to improve their mobility after being discharged from the hospitals, and by doing so, it will improve the life quality of stroke patients and their families.
- By implementing this proposed strategies, we expect to integrate health policies and social policies of long-term care services, and utilize community resources in the most cost-effective way to provide the public continuous care, and ensure continuous implementing long-term care health policies in the future.
- For those less severe and are qualify for home cares patients, they should be discharged from hospitals early in order to reduce the health care cost, and they will be monitored and cared by health professions to conduct routine home visit.
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