民國90年11月健保局實施「結核病醫療給付改善方案試辦計畫」，建立結核病個案管理專員制度，這代表臺灣的結核病防治工作已逐漸轉化為醫院為中心的個案管理模式（hospital-based models）；本研究的目的希望能瞭解結核病個案管理專員的執行過程面和工作內容及進一步探討與過去以社區為基礎的個案管理模式（community-based models）的差異。研究方法： 本研究是以台灣地區醫療機構為範圍，並以實際從事結核病防治「結核病病患照護管理」工作之個案管理人員為研究對象，共抽樣240家醫療院所。先後以電話訪問式問卷和焦點訪談，收集該院結核病個案管理作業流程及個案的管理模式。資料彙整後進行資料統計分析，並對本研究之各項成果預估進行檢定；另一方面，取樣台中地區四家醫院91、92、93、94年由個管師草創到完成時的完治率進行分析。主要發現：基本資料顯示衛生所的結核病個案管理工作人員相較於醫療院所，在專任結核病個案管理師和取得疾病管制局核發「結核病個案管理專員」證照方面，衛生所明顯不足(專任方面3.1% vs 34.6% p值0.003、證照方面 71.6% vs 6.3% p 值0.000)。在治療管理方面，55.8%的受訪機構有成立類似「結核病診治委員會」組織，討論收案病人治療情形，至於未成立類似「結核病診治委員會」組織的醫療院所，卻只有一成定期(每月或每季)參加衛生單位成立之「結核病診療諮詢小組」會議。每年合理個案管理數45.5%地區醫院、63.8%區域醫院和82.4%醫學中心都有信心每年處理100人個案。焦點訪談顯示大家都希望可以簡化文書工作，增加與患者的互動和衛教的時間。台中地區四家醫院過去四年由個管師制度草創到完成時的完治率有明顯改善。結論：臺灣的結核病防治工作已經逐漸轉型為以醫院為中心的個案管理，取代過去以衛生所為基礎的社區型的個案管理。醫療院所的結核病個案管理專員接受完整的專業訓練，應該可以扮演醫病關係的橋樑，結合醫療與公衛兩大系統，成為未來台灣防癆工作的尖兵。建議事項： 1.對於專任且取得疾病管制局核發「結核病個案管理專員」證照的醫院和個管師應給予鼓勵。建議以公務預算直接補助醫院「結核病個案管理專員」薪資。 2.簡化目前資訊軟體，減少文書作業，個管師就可以增加與患者的互動和衛教的時間。 3.落實稽查是否成立或參加「結核病診療諮詢小組」會議。 4.加強整合醫院與社區連繫，彈性配置人力。 5.加強專業訓練與統一的作業模式。 Abstract Objective: Since Bureau of National Health Insurance (BNHI) implemented a demonstration program of increasing TB medical reimbursement, also called quality payment program in 2001, the tuberculosis case manager was established in Taiwan hospital and health centers. The purpose of this study was to investigate the characters, work and load of TB managers after its implementation. Methods: The TB case managers in hospitals contracted with BNHI in 2005 participated in this study. The structured questionnaires were used to interview them by telephone or personal. The descriptive statistics were applied to analyze the perceptions and difficulties they faced in the current TB control and prevention program. Static analysis was conducted to analyze the associated factors with their satisfaction and difference among stratified hospitals and health centers. Results: The baseline characteristics revealed more full-time and licensed TB case manager worked in hospital such as medical center rather than local clinics and health centers. 55.8% visited hospital set up the committee of tuberculosis consultation, whereas only 10% staff had participated the meeting held by public health office. Almost every visited hospital put perception education into practice including patient and his or her family. For the patient admitted in hospital, the education was carried out by ward staff (55.3%) or case manager (35.1%). However, the case manager in community health center did not bring it into practice. There were 11.3% case manager made a refer note when patient was discharged. The optimal number of case management might be less than 100 per year. They also wish it spend more time to interact with patient in state of dealing Conclusions and suggestions: Hospital-based models case management of TB has developed in Taiwan during the past several years in state of community-based models case management. Overall speaking, it implicated TB case manager will play the role of communication channel between the aspect of public health and medical specialist. Based on the results of this study, the following suggestions were offered to improve the current program. 1. Encourage the employment of full-time and licensed case manager. 2. In order to enhance the interaction between patients and case manager, the software of registration should be improved. 3. To inspect the content of meeting for tuberculosis committee in hospital and the bureau of public health intensively. 4. Reinforce the cooperation between hospitals and community. 5. Unifying the model of case management and document. Keywords: community-based models case management, hospital-based models case management, tuberculosis case manager
