The Experience of Setting an Integrated People-Centered Health Evaluation and Care Model in a Community in Taipei

Introduction: We have launched the integrated home care project since 2016. The initial integrated home care project divided the patients into 3 stages: 1. Home care 2. Severe home care 3. Home palliative care. Later, the modified project added on stage 0 for evaluating the potential population who might need the further integrated home care. However, there are still some people who need the medical resource don’t know the policy. Moreover, some people are hesitated about let the ’strangers’ entering into their homes. Objective and targeted population: We wanted to find out those people who needed the integrated home care project actively. Hence, the doctor, the social worker, the case manager and the community management committee in one community held a meeting to discuss the medical demands of the population living in the community, and then set up the targeted population of visits. The targeted population would be: 1. Have definite medical demands 2. Have difficulty in go to the hospitals. The community offered a public space, where the doctor could do the evaluation for those who would like to see the doctors but were hesitated to let the strangers entering their homes. Besides, if the patients and their family members agreed to accept home care visits, at least one member of the community management committee would accompany the medical team into the inhabitants’ homes. The medical team and the community management committee used one communication software to contact others for further visits. If there were some training courses for caregivers/ volunteers, the medical team would offer the information to the community management committee. Impact: From March 2018 to August 2018, the doctor, the social worker and the volunteer had visited the community for 8 times and evaluated 20 ( 20/224 families, 8.93%) stage 0. 1 of them was referred to the neurologist for confirming dementia, 1 of them was referred to the dietitian for nutrition evaluation and diet education, 1 of them was referred to CV OPD for heart failure survey, and 4 of them accepted at least once further home care visit. The elderly inhabitants, especially the female, would gather in the public space to await the medical teams. The community management committee noticed the inhabitants became more happier after the medical team intervention. Comments on transferability: Since the community management committee was composed of the inhabitants themselves in the community, their existence would let the inhabitants had more willing to accept the medical team’s visits for the first time. The advantage was that they own a public space which could be utilized to be a mini clinic. Some health centers or offices might also be a temporary clinic if needed. In our opinion, the model may be applied to other communities. Conclusions: Via the cooperation of the medical team and the community management committee, we could find out more people who need further medical management. Although not all of them would accept further integrated home care, we could transfer them to suitable professionals.