STUDY ON CARE-COORDINATE OF COMMUNITY HEAITH NURSE FOR SUPPORTING TO FRAIL EDERLY PERSONS AND THEIR FAMILIES AT HOME

摘要本研究的目的是分析社区卫生护士对使用长期护理保险（LTCI）的居家体弱老年人及其家庭照顾者的护理坐标。LTCI ACT成立于1997年，成立于2000年。居家护理的LTCI服务种类包括：家政服务、洗浴服务、护理服务、康复服务、日托服务、医疗服务、日间服务、shot stay in care facility、福利设备、改装或修理房屋。护理管理人员为ltci受益人制定护理计划，在日常生活活动方面提供帮助，并保持他们健康的生活方式。但独自制定职业规划是困难的。LTCI服务由各种正式和非正式组织、各种医疗、健康和福利领域的专家和许多工作人员提供。结果表明，在LTCI - ACT之后，许多医院已经组成了综合社会支持系统，与其他医院合作，支持患者在医院内外的家庭护理。护理管理者希望社区卫生护士一直参加护理会议并监督解决老年人及其家庭护理人员日常生活中的各种问题。社区卫生护士的护理协调职能是与护理经理合作，在社区内引入医疗、健康和福利资源，协调家庭护理服务人员与ltci受益人之间的相互关系。此外，还包括开发新的正式和非正式资源，以支持体弱多病的老年人，并评估后续方案规划和服务机构。

The objective of research is to analyze the care-coordinate of community health nurse for supporting the homebound frail elderly persons with physical or mental health problems and their family caregigers, having used Long-term Care Insurance(LTCI). LTCI ACT was established in 1997 and started in 2000. Kinds of LTCI services in home care are home-help, bathing, nursing, rehabilitation, daycare, medical care, dayservic, shot stay at care facility, welfare equipment, modifying or repairing house. The care manager makes in a careplan of 1LTCI beneficiaries, to provide assistance with activity of daily living and to keep their healthy lifestyle. But it is difficulty to make in careplan the caremanager by itself.The LTCI services is provided by various formal and informal organizations, various specialist of medical, healthy and welfare area and many staffs. It is come out, after LTCI ACT, many hospitals have been to constitute the synthetic social support system to collaborate with other hospitals and to support patint's homecare being in and out a hospital.The caremanagers wants that community health nurse have been attending the care conferences and supervicing for being solved various trouble in the daily life of elderly persons and their family caregives.The function of care-coordinate of community health nurse is to go into partnership with the caremaneger, to introduce medical, healthy and welfare resouce within the community, to coordinate interperonal relationship between homecare services staffs and 1LTCI beneficiaries. Moreover it is covered to tap new formal and informal resource for supoorting frail elderly persons and to evalute followup program planning and service institute.