台灣老人健康照護現況與展望. Current Status and Perspectives of Elder Care in Taiwan 陳慶餘教授 國衛院老年醫學研究組台灣老年學暨老年醫學會

Transcription

1 台灣老人健康照護現況與展望 Current Status and Perspectives of Elder Care in Taiwan 陳慶餘教授 國衛院老年醫學研究組台灣老年學暨老年醫學會

2 Content 老人健康照護現況 老化社會之桃戰 因應架構與策略 在地老化先導計畫 老人健康照護品質 2020 老人健康照護指標

3 Life Expectancy in Taiwan Life expectancy Male Female 1985v.s yrs 1985v.s yrs v.s yrs 1995v.s yrs Year

4 老人自述曾經醫師診斷罹患慢性病項目數 性別 年齡 1 項 2 項 65 歲以上 85% 64% 歲 82.1% 59.7% 75 歲以上 87.8% 68.7% 男性 歲 75 歲以上 76.5% 84.6% 52.5% 64.8% 女性 歲 75 歲以上 87.8% 91.5% 63.8% 73.2% 註 :1. 本表所稱慢性病, 包括高血壓 糖尿病 心臟病 中風 肺或呼吸道疾病 ( 支氣管炎 肺氣腫 肺炎 肺病 氣喘等 ) 關節炎及風濕症 胃潰瘍或胃病 肝膽疾病 髖骨骨折 白內障 腎臟疾病 痛風 脊椎骨骨刺 骨質疏鬆等 14 項慢性病 2. 資料來源 : 台灣地區中老年身心社會生活狀況長期追蹤調查 (2003)

5 年台灣老人健保醫療照護使用情形單位 :% 1996 年 2000 年 2005 年 10 年平均 10 年成長幅度 (%) 平均門診就診率 平均每人每年門診次數 平均每年住院就診率 平均每人每年住院日數 資料來源 : 中央健康保險局

6 年台灣平均每人每年個人醫療費用 費用 ( 元 ) 2005 年 2006 年 年齡別 合計 男 女 合計 男 女 總計 27,433 26,008 28,907 28,736 27,039 30, 歲 15,598 16,389 14,735 18,491 19,376 17, 歲 6,708 6,599 6,827 8,631 8,760 8, 歲 6,579 5,095 8,121 10,879 11,792 9, 歲 9,585 8,356 10,841 12,224 9,687 14, 歲 19,178 15,772 22,641 20,018 17,406 22, 歲 45,330 38,775 51,834 44,874 37,716 51, 歲 87,441 87,604 87,289 81,677 77,299 85, 歲 124, , , , , , 歲以上 115, , , , ,705 87,954 資料來源 : 行政院衛生署衛生統計資訊網 國民醫療保健支出 全民健康保險 醫療統計年報

7 Death Number and Mortality in Year 0f 1985,1995 and 2005 Yr Total Death Number Crude Mortality Standardized Mortality ,121 44,216 33,556 13, ,954 46,701 46,005 25, ,957 47,026 50,430 41,

8 台灣 65 歲以上人口主要死因死亡率發展趨勢 惡性腫瘤心臟疾病肺炎事故傷害高血壓性疾病 腦血管疾病糖尿病腎炎 腎徵候群及腎性病變慢性肝病及肝硬化支氣管炎 肺氣腫及氣喘 1200 每十萬人口死亡率 年

9 Rank order of chronic conditions for people age 65 and over, 2005 Hypertension 42 Stroke 7 Cataract Osteoporosis Hyperlipidemia Asthma Liver diseases 5 5 Heart diseases 19 Dementia 3 Diabetes 17 Mental diseases 3 Arthritis 15 Cancer 3 Gout Renal diseases Respiratory diseases Parkinson s diseases Epilepsy Note: 1. Rates are weighted to represent the whole Taiwanese older population. 2. Percentages are rounding and may not totally be 100. Data source: National Health Interview Survey, 2005

10 100 Percent Self-rated general health status of people age 65 and over, 2001 & 2005 Good to excellent Fair Poor Taiwan, 2001 Taiwan, 2005 Note: 1.Rates are age- and sex- standardized to the 2000 Taiwan older population. 2.Proxy respondents (12.4% in 2001 and 8.6% in 2005) are excluded. 3."Good to excellent" includes response categories of "good", "very good", and "excellent". 4.Percentages are rounding and may not totally be 100. Data source: National Health Interview Survey, 2001 & 2005

11 Comparison of Increasing Aged Proportion in Various Countries Italy Japan Taiwan USA France UK China Singapore

12 Future Trend of Aged Populations in Taiwan

13 Expected Distribution of Elder Groups in Taiwan from 1976 to 2051

14 Expected Distribution of Elder Groups in Taiwan 7,000 人口數 (1,000) 6,000 5,000 4,000 3,000 2,000 1, , 年戰後嬰兒潮進入老年, 老人比率以倍數增加!! 1, , , , ,376 1,185 6, 年份 1,594

15 Increased Prevalence of Functional Limitations in Taiwan, 年齡愈老者功能障礙比率增加 (50%)! Zimmer Z, Martin LG, Chang MC. Changes in functional limitation and survival among older Taiwanese, 1993, 1996, and Popul Stud (Camb ). 2002;56:

16 醫療費用隨失能程度倍增 Figure 1. Diagram showing the relationship between functional status and use of health care service (A. Average Health Care Costs among Older People with Different Level of Function. B. Rate Ratio and Relative Proportion Accounted for Total Participants and Total Health Care Expenses among Older People with Different Level of Function.) The bars in figure 1A indicate 95% confidence interval of average health care costs. *Rate ratio=% of total health care expenses / % of total participants. 台灣衛誌 2007

17 台灣老化社會之挑戰 Meeting Challenges of Aging Society in Taiwan Reducing Productivity : The ratio of on-job/retired from 7.4 in 2005 down to 3.3 in 2026 and 1.7 in Increasing Social Welfare Expense: The proportion of disable over total population increasing from 1.3% in 1995 and 1.7% in 2000 increasing to 2.4% in 2010, 3.5% in 2020, 5.6% in 2030 and 7.0% in High Utilization of Medical Care: Under current hospital-based sub-specialized care system, the high OPD visit frequency (average 15 times per person each year) reflected inappropriated use of medical resources. Increasing Medical Expense : The OPD expense of the elderly about 3 times more and hospital expense about 6 times more (average 4.4 times) than the younger in 2000 NHI budget.

18 老年周全性照護之功效 Benefits of Geriatric Care Preservation of physical function or slowing of decline. Dramatically increase patient and family satisfaction. Decreased time spent in an inpatient setting such as a hospital or nursing home. Improved social functioning in the community. Decreased rates of depression. Increased access to social support services. Reduced disability.

19 老年周全性照護之範疇 時間 : 老 病 失能 死亡 空間 : 居家 醫療院所 照護機構 服務 : (1) 需求 : 照護養護 (2) 功能 : 醫療社福 品質 : 老年專科醫師 老年照護團隊

20 如何建構整合性老人照護體系 醫學教育 老年專科醫師, 老年照護團隊 老年醫學科部 醫療體系 中期照護機構, 老年照護部門社區健康支持網絡, 診療模式 衛生行政社會福利健保給付

21 策略 :Strategies for Implementing Elderly Healthcare System in Taiwan (Prof. Tai NHRI 2005) 1. Fulfilling Geriatric specialty board examination. 2. Promoting Professional Training for Geriatric Physicians and Related Healthcare Professionals. 3. Editing & Publishing Treatment Guidelines for Common Geriatric Diseases. 4. Implementing Comprehensive Researches in Gerontology. 5. Designing and Maintaining a Gerontology Website. 6. Optimizing the Resources of NHRI Forums. 7. Setting Up a Geriatric Clinic & Demonstration Center. 8. Normalizing the Training of Gerontologists and Geriatricians in Taiwan. 9. Establishing Comprehensive Eldercare System. 10.Including Gerontology as an Essential Part in Hospital Accreditation & Review.

22 Establish a comprehensive fellowship training program to train competent candidates graduated from internal medicine and family medicine of teaching hospitals (total 15 fellows from 7 teaching hospital in 2 years). Work with these well-trained young staffs to facilitate further educational efforts in geriatrics, promote the quality of health care for the elderly, to enhance geriatric research in Taiwan. Create new geriatric care departments to succeed and expand geriatrician training programs (3 medical centers founded in 2007, 4 in 2008). Publish geriatric training manual to assure quality of geriatrician training for accreditation. NHRI Training Program in Clinical Geriatrics (July 1, 2004 June 30, 2006): Achievements ( 成果 )

23 Geriatric Geriatric Fellowship Training Program Program (NHRI, July 2004) RCW Home care Neurology Psychiatry Rehabilitation NTUH Acute ward Chang-Gong Acute ward Nursing Home Hospice Palliative Care Specilaty Acute Care LT/EOL Care

24 Visiting Professors of Geriatric Fellowship Training, NHRI Dr. Ahronheim Open Ceremony Taipei, Taiwan Dr.Kennedy AGS Meeting Orlando&Chicago New York USA Drs. Bloom Dr. Lanz Dr. Boal Dr Morrison Dr. Sherman Dr. Granieri (5) 2005(6)

25 老年醫學專業之新思維 Innovative Approaches of Geriatrics to the Care of Older Adults Interdisciplinary team care applied successfully in hospital, outpatient, home, and nursing-home settings Diagnosis and treatment of common geriatric conditions such as falls, urinary incontinence, delirium, and poly-pharmacy. New insights into the heterogeneity of aging, ranging from frailty to successful aging, in which good health and functional ability persist well into older age. Infused into other areas of health care (e.g., ethics, hospice and palliative care, and chronic disease management), medical professions, hospital accreditation and management. Journal of the American Geriatrics Society Volume 53 Page S245 - June 2005

26 Geriatric Fellowship Training Manual

27 Community Geriatric Hospital Reform Project (DOH) During 2005, two community hospitals were assigned to Gerontology Society of Taiwan (GST) for steering and became demonstration centers to train eldercare manpower and improve eldercare in community. With quality improving accreditation program, various geriatric teams including geriatrician, geriatric nurse, social worker, physical therapist, occupational therapist and nutritionist were organized. On-job training course and quality of service were fortified and supervised by GST. Then in 2006, a new policy took action to subsidize all community hospitals in counties/cities of Taiwan where elder population over 11%. Up to Feb,2007, total 19 community hospitals have been approved by DOH to provide intermediate care. Using medical development fund, DOH continues to subsidize these geriatric hospitals till end of 2008.

28 Community Demonstration Center for Eldercare in Northern Taiwan

29 Community Demonstration Center for Eldercare in Central Taiwan 在此輸入副標題

30 Distribution of 19 community hospitals in Taiwan(2007) Miao-Li 12.42% (4) Tai-Chong City 7.31% County 8.07% 新竹市 8.92% 新竹縣 10.81% Tau-Yuan 7.69% Taipei city 11.22% (3) County 7.03% Chang-Huai 11.3% (5) Ie-Nan 11.86% Yun-Lin 13.62% (1) Huai-Lan 11.58% Chia-Ie City 9.93% County 14.30% (1) Tai-Nan city 8.64% County 12.05% (2) Nan-Tou 12.25%(1) Kau-Shiong city 8.53% County9.35% Ping-Tong 11.35% (2) Tai-Tong 12.17% Source:Household Dpt2008

31 National Health Care System Reform after 2003 SARS Era Medical service Medical Care Structure Health Administration Tertiary Advanced Care Research and Teaching Rare Case Care Nation Medical Center Teaching and Accreditation Research National Health Department and Bureau of Insurance Secondary Care Regional Care (General and Special Care) Promote Community Care Continuing Education Consultation and Referral System Region Hospital Community Medical and Public Health Group Teaching and Accreditation Case Management Informatics Platform County Health Bureau and Division of Insurance Primary Care Community Preventive Services First Contact Care Long-term Care Health Promotion Local Community Community Hospital Health station Family Physician Geriatric hospital for intermediate care

32 National Strategies in Response to Aging Society In response to an aging population, the government should expedite the establishment of a stable and viable fiscal and budgetary system to support the development of policies for extended care-giving for the elderly that is diversified, community-based, high-quality, and comprehensive, taking into account differences in conditions between genders, urban and rural areas, cultures, professions, economic status and health conditions. Conclusion of Conference on Sustaining Taiwan's Economic Development (CSTED) July 27, 2006

33 Social welfare Health Administration Health Insurance Resources Integration Disease Management Insurance requirement Community health supporting Network for the elderly Self-care and Preventive Services Community Health Care Profession Care Information Provision Community Elder People Constructive Interaction Quality of Life Geriatric care Team Community Elder Health Care Framework

34 Continuum of Healthcare Medical Care Life Care Emergency Care Acute Care Postacute/ Chronic care LTC/HPC Electronic record Teleconsultation Remote Monitoring Community Hospital Nursing Home Day Care Center Home Care

35 Promoting Service Enterprise Development for Elder Care in Taiwan (Ministry of Economic Affairs, ) Expanding health technology Implementation and creative services for safety protection, telecare, transportation, traveling and self care education for the elderly Service system plan for Chronic disease management Living and recreation Creative service plan Service system plan for Chronic disease management Living and recreation Creative service plan Residential, community or emergent care system plan for the elderly Residential, community or emergent care system plan for the elderly Residential, community or emergent care system plan for the elderly 2006 U care for the elderly 2007 Creative health service 2008 Creative health service

36 老人健康照護原則 Principles of Geriatric Care Asking the right questions Clinical alertness Advocacy Integration of the family s and other caregivers role Emphasis on function Accurate diagnosis Serial observation Recognition that even a good intervention may produce harm Setting of clear goals, identifying target symptoms and organizing good follow-up Pursuit of the noncompliant or no-show patient Allowing sufficient time for recovery of function Postponement of dependency Communication

37 Person-centered health communication: Process to promote health behavior of elder people Educate Assess needs Identify goals Eliminate barriers Provide role models Supply verbal encouragement Continue reinforcement and rewards

38 Implementation of Principles of Geriatric Care in Practice Quality improvement services Patient-centered Goal-directed care Evidence-based practice Informatics technology (U-Care)

39 Goal-directed: Comprehensive Integrated Care Model for the Elderly Chronic Diseases & Rehabilitation therapies Treatment of barriers Information giving Skills training Aids & appliances Adaptations Environment Co-operation Assistance Legal Societal Body functions and structures Capacity Activity Participation Goal setting Encouragement Behavior change Personal factors

40 Domains of Quality End-of of-life Care (IOM, 1997) (based on bio-psych-socio-spiritual well-being) Overall quality of life Physical well-being and functioning Achieving a sense of spiritual peace and well-being Patient perception of care ( Advanced directives) Family well-being and functioning

41 Vision of Optimal Care in Aging Model Healthy Aging Positive Aging Active Aging Successful Aging Focus (Task) Organ System (Diseases) Person-centered (Depression) Activity (Disable) Participation (Death) Goal Vigor Happiness Dignity Wisdom

42 Strategies of Preventive Geriatric Care ( Healthy People 2020 ) 1. Primary and secondary disease prevention 2. Tertiary disease prevention 3. Prevention of frailty 4. Prevention of accidents 5. Prevention of iatrogenic illness 6. Prevention of psychosocial illness

43 Geriatric Integrated Care Plan (1) Activity Primary and secondary disease prevention Tertiary disease prevention Services for participation Screening Counseling Vaccination Chemoprophylaxis Disease management of chronic illness: Practice guidelines and protocols Formal disease management programs Cooperative Health Care Clinics Specialty referral Priority target population Healthy and functionally independent Chronically ill Prevention of frailty CGA Exercise: Aerobic Weight training Flexibility Balance Diet Healthy and chronically ill who are functionally independent

44 Geriatric Integrated Care Plan (2) Activity Prevention of accidents Prevention of iatrogenic illness Prevention of psychosocial illness Services for participation Falls prevention Driving tests Seat belts Home safety checklist PT/OT referral for environmental Case management GEM Pharmacist consultation ACE units Advance directives Depression screening Increased social contact Senior centers Social clubs Increased self-worth Volunteer work Caregiving Pets Priority target population Chronically ill and frail Chronically ill and frail All older adults

45 Five Indicators of 2020 Healthy Elders Frailty prevention with annual comprehensive elder health examination Prevention of falls Stroke disable prevention and promotion of geriatric rehabilitation Depression screening and prevention Promotion of advance directives

46 結 語 教育嬰兒潮老人族群負起自我保健的責任 提供功能導向目標管理的照護模式 實施周全性老人健康檢查 推動老年人預防醫學 ( 養生保健 ) 提昇老年人生活品質 延長健康生存餘命

47 Thank you for your attention