A Study on the collaboration between social worker and home helper for elderly in need of nursing care with difficulties for treatment-A discussion focusing on alteration of user's living and helping prosess under the care management system

根据以往的研究，我们发现1)很难详细分析老年病例困难的原因和治疗方法，2)需要对治疗困难病例的讨论过程进行监控。因此，我们进行了如下案例的收集和分析；1)我们要求服务管理人员从他们所处理的所有病例中提取出治疗困难的病例，在将病例分解成模式后，我们对护理管理人员进行了访谈研究。2)我们要求服务提供经理以讨论格式和调查问卷的形式写出案例的原因和处理方法。我们请助手写下治疗困难的真实场景。3)对治疗困难病例的护理管理人员和服务管理人员进行重新访谈。有用的结论是以下四点；l)通过问卷对治疗困难病例的原因进行分类，确认了我们前几年研究的病例为典型病例。2)找出退化的预防点，治疗和监测功能的变化成为关键，使帮助者支持用户在家中生活。3)服务经理和护理经理在帮助者遇到困难时给予支持是很重要的。4)护理管理人员、服务管理人员、家庭帮佣及其与制度、服务、家庭关系等方面存在治疗困难后的问题。5)有困难的情况需要授权方法，在这种情况下，LSI正在使用。因此我们对护理人员进行了大规模集成电路培训计划。6)记录对于团队工作和协作非常重要，因此我们研究了多学科团队使用记录的方法。

According to the previous studies, we found that l) it is difficult to analyze causes of and treatment to the difficulties of the elderly cases in detail, 2) it needs to monitor the process for the discussion of the cases with difficulties for treatment. So we conducted collecting and analyzing cases like as below;1) we asked service offer managers to extract the cases with difficulties for treatment from all cases they were conducting, and after we broke cases into patterns we conducted interviewing research to care managers. 2) we asked service offer managers to write in the format for discusioning and in the questionnaire on causes of and treatment to the cases. And we asked helpers to write down real scenes with difficulties for treatment. 3) we re-interviewed to care managers and service offer managers about cases with difficulties for treatment.The useful conclusions is next four points; l) As a result of typing causes of cases with difficulties for treatment through the questionnaire, we confirmed that cases we had studied since previous years was typical cases. 2) Finding out preventive point of ingravescence, variations for treating and monitoring function become the key so that helpers support keeping the uses' life in their home. 3) It is important for service offer managers and care managers to support helpers while they meet difficult situations. 4) There are some issues following difficulties for treatment on sup-port by care managers, service offer managers, home helpers and their relationship along to the systems and services, family relation and so on. 5) The cases with difficulties need empowerment approach, and in its cases the LSI is being used. So we conducted the LSI training program to care workers. 6) Recording is important for team work and collabo-ration so that we examined the way of recording for using multidiciplinary team.