職能治療在後急性病患照護的
角色功能
急性期後のケアにおける作業療法の役割
The role and function of OT in post-acute Care
張婉嫈WAN-YING CHANG,
OTR, MS, 2022/12/3
2022/12/8

1急性後期照護的目標
急性期後ケアの目標
Goals of Post-Acute Care
1. Care recipients must be patients not requiring long-term hospitalization or premature placement ina long-term care facility.

2. The services provided should be based on a comprehensive assessment of the older patient andindividualized treatment plans drafted in accordance with the results of such assessments.
3. As much as possible, such service should seek to enhance patients’ independent, autonomous living
ability and have the ultimate goal of allowing patients to live independently at home.
4. Post-acute care services possess time restrictions, will not exceed 6 weeks as a rule, and will usually
last no more than 2 weeks.

5. Although the content of services must encompass all treatment areas, there must be individual
assessment mechanisms, individual case history records, and case history sharing procedures.

2022/12/8

Wang YC et al. 2019, https://doi.org/10.4235/agmr.19.0009

2

中央健康保險署-健保醫療計畫https://www.nhi.gov.tw/Content_List.aspx?n=5A0BB383D955741C&topn=5FE8C9FEAE863B46
2022/12/8

3

台灣全民健康保險急性後期整合照護計畫
台湾の国民健康保険の急性期後の総合ケア プラン
National Health Insurance Post Acute Integrated Care Program
Traumatic Neurological Injury PAC
Fracture PAC
Heart Failure PAC

Stoke PAC
2014/1/1

Frailty PAC

2015/9/9

2017/7/1

Burn PAC
2022/12/8

4

目標
目標
Purpose
1. Establish Taiwan‘s post-acute care model◦ improve the quality of post-acute care

2. Establish integrated transfer system(continuity of patient care )◦ acute phase → post-acute phase → chronic phase

3. Completeness and Effectiveness：◦ Provide positive and integrated care to patients in the golden period oftreatment◦ Restore functions or reduce disability◦ Reduce subsequent medical expenses for re-hospitalization

2022/12/8

5

照護模式
ケアモデル
care model
Inpatient
Acutemedicalcare

Post-acute
Care patient
assessment

Discharge
preparation

OPD CareDay care(Refer to social
resource services)

Home
care
2022/12/8

6急性後期整合照護住院模式
急性期統合治療後の入院モデル
Inpatient model of post-acute care
1. Regional/community hospital
2. Rehabilitation treatment
3. Service contents:
1. Personalized treatment plan
2. Interprofessional team integrativecare
3. Rehabilitation treatment
4. Home care skill guidance
5. Prevention and treatment ofcomorbidities and complications
6. Regular team evaluations
2022/12/8

Team members: Physician, Nurse, Specialist Nurse , Physical
Therapist, Occupational Therapist, Speech therapist,
Psychologist, Social worker, Nutritionist, Case megamerger
7急性後期整合照護日間照護模式
急性期後統合ケアデイケアモデル
Day care model of post-acute integrated care
1. All day (9:00-17:00)
2. Service contents:
1. Physician diagnosis
2. Outpatient rehabilitation treatment
3. Nursing care: Wound dressing, Urinary
catheter, Constipation
4. Refer social resources for counseling
5. Nutrition and dietary guidance
6. Functional recovery
7. Physical & mental rehabilitation

3. Individual therapy room or shelteredfield
2022/12/88

急性後期整合照護居家模式
急性期後統合ケアホームモデル
Post-acute integrated care home care model
1. Can not use Inpatient or
Outpatient Model
2. Service contents:
1. 30-50 mins. Home care by PT, OT,
or ST (Home care certification)
2. Education care giver, help patient
ADL function and social
participation
3. Evaluation and plan
4. Frequency: 6 times/week
5. Hospital release prescription tocommunity clinic
2022/12/8

9

成效評量
有効性評価
Effectiveness evaluation
1. Members: all staffs• Discharge evaluation to
Medical center
PAC service hospital
2. Meeting frequency: baseline,
mid-term, discharge, regularconvening rate 98%
PAC service• Initial evaluation about
regional hospital each professional tools
3. Meeting record: showed in/ clinic
medical records, signature form,
Medical Record Completion Rate
PAC service
100%
regional hospital • Mid-term evaluation
4. Medical record content:/ clinic
inclusive criteria, discharge
criteria, each profession goals,
PAC service• Discharge planning to longdischarge planning
regional hospital/ clinic
2022/12/8

term care /home care10

出院準備服務內容
退院準備サービス
Discharge preparation services
1. Provide consultation hotline
2. Home care advice
3. Rehabilitation treatment suggestions
4. Community medical resources referral service
5. Referral to social resource: ex. Long-term care center, Assistive technology rescore center
6. Suggestions for psychological counseling services
7. Referral to the home medical team of the "National Health Insurance Home Medical Care
Integration Plan"
8. Referral to the community medical group of "Family Physician Integrated Care Plan"
9. Other matters related to discharge preparation
2022/12/8

11

品質指標
品質指数
Quality index
Submit the implementation results report every six months
Mortality rate:𝑇ℎ𝑒 𝑛𝑢𝑚𝑏𝑒𝑟 𝑜𝑓 𝑐𝑎𝑠𝑒𝑠 𝑡ℎ𝑎𝑡 𝑑𝑖𝑒𝑑 𝑤𝑖𝑡ℎ𝑖𝑛 1 𝑦𝑒𝑎𝑟 𝑎𝑓𝑡𝑒𝑟 𝑡ℎ𝑒 𝑐𝑎𝑠𝑒 𝑤𝑎𝑠 𝑑𝑖𝑠𝑐ℎ𝑎𝑟𝑔𝑒𝑑
𝑁𝑢𝑚𝑏𝑒𝑟 𝑜𝑓 𝑐𝑎𝑠𝑒𝑠 𝑐𝑙𝑜𝑠𝑒𝑑 𝑏𝑦 𝑖𝑛𝑠𝑡𝑖𝑡𝑢𝑡𝑖𝑜𝑛𝑠 𝑖𝑛 𝑡ℎ𝑒 𝑐𝑢𝑟𝑟𝑒𝑛𝑡 𝑦𝑒𝑎𝑟 (𝑒𝑥𝑐𝑙𝑢𝑑𝑖𝑛𝑔 𝑑𝑒𝑎𝑑 𝑐𝑎𝑠𝑒𝑠)30-days Emergency revisit rate:𝑇ℎ𝑒 𝑛𝑢𝑚𝑏𝑒𝑟 𝑜𝑓 𝑒𝑚𝑒𝑟𝑔𝑒𝑛𝑐𝑦 𝑐𝑎𝑠𝑒𝑠 𝑤𝑖𝑡ℎ𝑖𝑛 30 𝑑𝑎𝑦𝑠 𝑎𝑓𝑡𝑒𝑟 𝑡ℎ𝑒 𝑐𝑎𝑠𝑒 𝑤𝑎𝑠 𝑑𝑖𝑠𝑐ℎ𝑎𝑟𝑔𝑒𝑑
𝑁𝑢𝑚𝑏𝑒𝑟 𝑜𝑓 𝑐𝑎𝑠𝑒𝑠 𝑐𝑙𝑜𝑠𝑒𝑑 𝑏𝑦 𝑖𝑛𝑠𝑡𝑖𝑡𝑢𝑡𝑖𝑜𝑛𝑠 𝑖𝑛 𝑡ℎ𝑒 𝑐𝑢𝑟𝑟𝑒𝑛𝑡 𝑦𝑒𝑎𝑟 (𝑒𝑥𝑐𝑙𝑢𝑑𝑖𝑛𝑔 𝑑𝑒𝑎𝑑 𝑐𝑎𝑠𝑒𝑠)Average length of hospital stay in post-acute careIntubation Removal Rate
Unplanned NG tube/Urinary catheter slippage rate
2022/12/8

12

6 Diseases for Post-Acute care program
腦中風/脳卒中/Stroke燒燙傷/やけど/Burn
脆弱性骨折/脆弱性骨折/ Fracture2022/12/8

創傷性神經損傷/外傷性神経損傷/Traumatic Neurological Injury
心臟衰竭/心不全/Heart Failure
衰弱高齡病患/衰弱した高齢患者/Frailty and Old Aged13收案與排除條件
承認条件と除外条件
Inclusion and Exclusion criterion
INCLUSION

EXCLUSION

1. Basic cognition, learning ability andwillingness

1. Severe impairment of consciousness
or cognition, severe mental illness

2. Sufficient physical fitness:

2. Long-term respirator dependence◦ Sit on wheelchair at least 1 hour without
support◦ Accept at least 1 hour of active
rehabilitation treatment every day

3. Active participate in rehabilitation
treatment plan

3. terminal disease
4. Bedridden for a long time, bodyfunction cannot recover

5. Cancer still requires follow-up
hospitalization

4. Good family support
2022/12/8

14

腦中風
脳卒中
StrokeModified Rankin Scale (MRS):3-4

Onset < 30 days
Neurological sign stable within 72 hrs
Vital sign: stableNo complication or under control
Training 3-6 weeks, max to 12 weeks

2022/12/8

15

評估工具
評価ツール
Assessment
CORE ASSESSMENTS

PROFESSION SELECTIVITY ASSESSMENTS

1. Modified Rankin Scale (MRS):3-4

1. Berg’s balance Test

2. Barthel Index (ADL function)

2. 6-minute walking test

3. Functional Oral Intake Scale (FOIS)

3. Usual Gait Speed

4. Mini Nutritional Assessment (MNA) 4. Mini-Mental Stage Examination
5. Euro QoL-5D

5. Fugl-Meyer Assessment-motor

6. Instrumental Activities of Daily
Living (IADL)

6. Motor Activity Log

2022/12/8

7. Speech function evaluation(Concise
Chinese Aphasia Test, CCAT)
16

燒燙傷
やけど
Burn
Inpatient
model
Barthel index≦ 80
Wound hasrecovered for >2monthsin poor condition
2022/12/8

Outpatient
model
After
inpatientdischarge
Max 3 months
Evaluation: +1
month for 3 times

6 hours burn continued education in
3 years
Evaluation items:
1. Barthel Index
2. Range of Motion
3. Vancouver scar scale
4. POSAS (patient and observer scar
assessment scale)
5. Burn Specific Dysphagia Severity Rating
Scale
6. Mini Nutrition Assessment (MNA Short
Form)
17

創傷性神經損傷
外傷性神経損傷
Traumatic Neurological Injury
Patients > 18 years old

Definition of medically stable：

Disabled due to traumatic nerve
injury1. Stable neurological condition

Onset: < 60 days

2. Vital signs are stable or controllable
in the past 72 hours

Significant and persistent moderatefunctional impairment

3. Complications have been stable orcontrollable

Barthel Index: 40 - 70

Stable medical conditions
Positive rehabilitation potential
Training 3-6 weeks, max to 12 weeks
2022/12/8

18

評估工具
評価ツール
Assessment
CORE ASSESSMENTS

PROFESSION SELECTIVITY ASSESSMENTS

1. Barthel Index (ADL function)

1. The Galveston Orientation andAmnesia Test

2. Lawton-Brody Instrumental
Activities of Daily Living (IADL)

3. Euro QoL-5D

2. Rancho Los Amigos Cognitive
Functional Grading
3. The Canadian Occupational
Performance Measure

4. Speech therapy evaluation

2022/12/819脆弱性骨折脆弱性骨折
FracturePatients > 18 years old

Exclusion: Spinal Cord Injury

Including: Hip, Spine, Knee, non–stable Pelvic fractureTraining 1-2 weeks, max to 3 weeks

Operation < 30 days

Barthel Index: 40 - 70
No complications, or complications
but controllable and stable symptoms

Evaluation items:
1. Barthel Index
2. Numerical Rating Scale；NRS
3. Harris Hip Score

No intensive medical intervention,
testing or oxygen use
Positive rehabilitation potential
2022/12/8

20

心臟衰竭
心不全
Heart Failure
INCLUSION
Heart failure: left ventricular Ejection fraction≦ 40%
ACC/AHA Stage C~DHeart failure: Ejection fraction ≧ 40% +acute decompensation inpatientAcute myocardial infarction + heart failure:
left ventricular Ejection fraction ≦ 40%
Training max to 6 months

2022/12/8

EXCLUSION
Survival period is < 6 months due to non-heart failurerelated diseases
End stage of severe heart failure and cannot recover withina short period of timePatients or families have no willingness to participate
Scheduled to undergo coronary artery bypass surgery or
heart valve surgery within one month
Currently undergoing kidney dialysis or waiting for a kidneytransplant.
Severe lung disease requires long-term home use of oxygen.
Inability to agree on treatment with other specialists

21

標準
標準
Criterion
1. Cardiologist
Doctor: 6 hours continued education
for heart failure care
2. Cardiac surgeon
3. Specialist Nurse(Heart failure case
Case manager:18-20 hours continued
manager)
education for heart failure careN3， Cardiology Ward >3 years or Cardiology
4. Psychologist
ICU> 2 years
5. Social worker
Each nurse care < 50 cases
6. Nutritionist
Case loading ≦ 25 → combine other work
loading
7. Physician medicine and rehabilitation
25 ≦ Case loading <50 → only responsible
8. Physical therapist
care heart failure cases
9. Occupational therapist
10. Pharmacist
2022/12/8

22

評估工具
評価ツール
Assessment
CORE ASSESSMENTS

PROFESSION SELECTIVITY ASSESSMENTS

Lawton-Brody Instrumental Activities of Daily
Living (IADL)Minnesota Living with Heart Failure
Questionnaires (MLHFQ）

Euro QoL-5D

The Kansas City Cardiomyopathy
Questionnaire6-minute walking test
New York Heart Association functional class I ~IVMini Nutrition Assessment (MNA Short Form)Cardiac ultrasound (Echocardiography)

ACEI or ARB or ARNI
Beta blocker
2022/12/823

衰弱高齡病患衰弱した高齢患者
Frailty and Old Aged

≧75 years old

Diagnosis: Parkinson's disease,dementia , chronic obstructive
pulmonary disease, Chronic Kidney
Disease (> Stage III)72 hours <Admission <30 days
Clinical Frailty Scale，CFS: 5-7
Training 2-3 weeks, max to 4 weeks
Doctor need >6 hours GeriatricTraining

2022/12/8

24

評估工具
評価ツール
Assessment
1. Barthel Index

2. IADL
3. Clinical Frailty Scale
4. SMPSQ
5. Geriatric Depression Scale-5 item
(GDS-5)

6. Confusion Assessment Method(CAM)
7. STEADI (Stopping Elderly Accidents,
Deaths & Injuries)
8. Beers Criteria for Potentially
Inappropriate Medication Use inOlder Adults
9. Mini Nutrition Assessment (MNA
Short Form)
10. EQ-5D

2022/12/8

25

支付標準
支払基準
payment standard
INCLUDED FEE (NO MORE CHARGED)

EXCLUDED FEE (EXTRA-CHARGED)

Hospitalization

Medicine

WardPharmacy service

Nursingtreatment and disposal fee

Examination

Operation

Rehabilitation treatment

Splint

N-G tube irrigation and diet2022/12/8

26

費用
料金
Fee: bonus for > 75 years old
Inpatient

Outpatient

Home careBurn-PAC

HF-PAC• 1,358~3,729
points• High dose:
3~5time/day• Regular
dose: 1~2
times/day• 1,338~2,538
points• Dose: 2~4times/day• 1,455
points/time• Dose: 1~6times/week• 480~600
points/time• 600
points/time

2022/12/8

27

職能治療項目
作業療法プログラム
Occupational Therapy Program
PACOT1 姿態訓練

姿勢トレーニング

Posture training

PACOT2 被動性關節運動

受動的な関節の動き

Passive Range of Motion
Exercise

PACOT3 坐站平衡訓練

座位・立位のバランストレーニング

Sit-Stand Balance Training

PACOT4 移位訓練

シフトトレーニング

Transfer Training

PACOT5 減痙攣活動

抗痙性活動

Anti-Spasticity Activity

PACOT6 運動知覺訓練

キネシオロジートレーニング

Kinesiology Training

PACOT7 知覺認知訓練

知覚認知トレーニング

Perceptual Cognitive Training

PACOT8 肌力訓練

筋力強化

Muscle Strengthening

PACOT9 協調訓練

調整トレーニング

Coordination Training

PACOT10 動作再學習技巧 動きの再学習テクニック
2022/12/8

Movement Relearning
Techniques28職能治療項目
作業療法プログラム
Occupational Therapy Program
PACOT11 上肢(下肢)功能訓練

上（下）肢の機能訓練

Upper(lower) extremity function
training

PACOT12 日常生活活動功能訓練 日常生活機能訓練の活動

ADL training

PACOT13 休閒運動治療

レクリエーション運動療法

Recreation and sport therapy

PACOT14 活動治療

活動療法

Activity therapy

PACOT15 輔具評估及訓練

補助具の評価とトレーニング Device evaluation and training

PACOT16 副木製作

添え木

Splinting

PACOT17 失能防治介入

障害予防介入Prevention disability intervention

PACOT18 上(下)肢矯治性治療

上肢（下肢）の矯正治療

Muscle Strengthening

PACOT19 感覺功能再訓練

感覚の再訓練Sensory function retraining

PACOT20 居家環境評估與改造

住宅環境の評価と改修

Home environment evaluation andremodeling

2022/12/8

29

職能治療在後急性病患照護的
角色功能
急性期後のケアにおける作業療法の役割
The role of OT in post-acute Care

2022/12/830

改善日常生活功能
日常生活動作の機能改善
Improve function in ADL and IADLs
Both PAC programs would significantly improve
the physical function and quality of life inpatients with hip fractures. (Lee MC et al. 2022)

2022/12/8

 PAC program significantly promoted recovery offunction in stroke patients and helped them toreturn to their home and community. (Lai CL et al. 2017)31改善日常生活功能
日常生活動作の機能改善
Improve function in ADL and IADLs

PAC data base N=436，Excluded 102 patients,◦ Non-PAC group (N=212, 63%)
◦ PAC group (N=122, 37%)

BI, MNA-SF, EQ-5D, Instrumental ADL, and MMSE PAC group were better than non-PAC group2022/12/8(Chang KV, et al. 2022, https://doi.org/10.1038/s41598-022-16984-9)32

改善日常生活功能
日常生活動作の機能改善
Improve function in ADL and IADLs

2014/03-2016/09， 6839
consecutive stroke patients

Functional status had improved in
87.5%
Mean modified Rankin Scale scorefrom 3.7 to 3.0

Three years of the nationwide post-acute stroke care program in Taiwan
Hsieh, Cheng-Yang; Tsao, Wei-Chia; Lin, Ruey-Tay; Chao, A-ChingJournal of theChinese Medical Association81(1):87-88, January 2018.
doi: 10.1016/j.jcma.2017.09.003
2022/12/8

33

改善日常生活功能
日常生活動作の機能改善
Improve function in ADL & IADLs
The functional recovery in patientswith hip fracture was significantly
increased at 2 weeks after
comprehensive rehabilitation relative
to that of the control group.

The improvement in patients withhip fracture was better in the PAC
group than in the control group at the
2-weeks, 3-months, and 6-months
follow-ups.

2022/12/8

Wang YJ et al. 2019, doi:10.6315/TJPMR.201906_47(1).0002

34

降低死亡率與醫療花費
死亡率と医療費を削減
Reduce mortality and medical costs

Hip fractures patients received inhome orcommunity hospital post-acute care following
surgery, their motor function could be recovered
within a short time and long-term mortality
would drop significantly. (Peng LN et al. 2016)

2022/12/8

 The home-based PAC program demonstrated thebest cost-effectiveness ratio for BI (NTD 554) andEQ-5D (NTD 41948). (Lee MC et al. 2022)

Lee MC et al. 2022, https://doi.org/10.1016/j.jfma.2022.01.002

35

降低死亡率與醫療花費
死亡率と医療費を削減
Reduce mortality and medical costs
2014/03-2018/10，910 patientswith stroke between were separated
into:• PAC group (at two medical centers)• non-PAC group (at 3 regional
hospitals and 1 district hospital)
Total direct medical cost: PAC < nonPAC
Functional status: PAC >non-PAC
One-year rehabilitation training: PAC>non-PAC
2022/12/8(Chiu CC et al. 2021, https://doi.org/10.3390/brainsci11020161

36職能治療在後急性病患的照顧
急性期後の患者のケアにおける作業療法
Occupational therapy in Post-Acute Care
Proactive participation at the discharging planningPatients, the families and other health care professionals can all benefit
Patient-centeredImprove patient’s ability to self careEnhance the performance of activities of daily lifeReturn to normal community life as early as possible (such as fall prevention)
Shorten hospital stay
Reduce health care expenses

Achieve a satisfactory recovery both physically and mentally
2022/12/8

Shih JM et al. 2019, doi:10.6200/TCMJ.201906_16(2).0002; Kao YH. (J of Med Health. 2018;7(2):45-56
Lai HJ et al. (J Med Health 2021; 10(2):73-82

37

結論
結論は
Conclusion

Enhance
ADL

Integrative
team work

Reducemortality

2022/12/8

PostAcute
Care

Improvefunction

Reducemedical
cost
38

謝謝聆聽
聞いてくれてありがとうThanks for listening

2022/12/8

39