李淑杏LEE,SHU-HSIN許依環Hsu,Yi-HuangHsu護理學系長期照護碩士在職專班2026-10-282031-08-2920262026-07-22https://handle.ncl.edu.tw/11296/p7pacfhttps://scholars.csmu.edu.tw/handle/123456789/34617腦中風為我國成人失能及長期照護需求的主要原因之一，不僅造成患者肢體功能障礙與日常生活能力下降，亦常伴隨心理適應困難與憂鬱情形，進而影響個案生活品質及增加家庭照顧負荷。近年來，政府積極推動出院準備服務與長期照護資源之銜接，透過居家復能服務協助個案恢復功能、延緩失能及提升生活自立能力。然而，國內針對出院準備服務銜接居家復能成效之實證研究仍相對有限。目的：本研究旨在探討腦中風個案接受出院準備轉銜長期照護居家復能服務後，對日常生活功能、照顧管理需求及憂鬱情形之影響，以作為未來臨床照護實務及長期照護政策發展之參考。方法：本研究採單組前後測準實驗研究設計（one-group pretest– posttest quasi-experimental design），以臺灣中部某醫療機構接受 出院準備服務並轉銜長期照護居家復能之腦中風個案為研究對象，共納入40位符合收案條件之個案。研究期間為12週，由跨 專業團隊依據個案功能狀況及復能需求提供個別化居家復能介入，每週至少1次，共12次。研究分別於介入前（T0）、介入 後第4週（T1）、第8週（T2）及第12週（T3）進行評估。 研究工具包括基本日常生活活動量表（Activities of Daily Living, ADL）、照顧管理評估量表（Care Management Scale, CMS）及簡式老年憂鬱量表（Geriatric Depression Scale-15, GDS-15）。資料分析採描述性統計、重複量數變異數分析（Repeated Measures Analysis of Variance, Repeated Measures ANOVA）及廣義估計方程式（Generalized Estimating Equations, GEE）進行分析，統計顯著水準設定為 p＜.05。結果：研究結果顯示；腦中風個案接受居家復能介入後，日常生活功能隨介入時間呈現持續改善趨勢，ADL平均分數由介入前64.13±6.39分提升至介入後第12週73.50±5.57分，四個時間點之差異達統計顯著（p＜.001）。照顧管理需求亦隨介入逐步改善，CMS於不同評估時間點之變化達統計顯著（p＜.001），顯示個案對照護資源之依賴程度逐漸降低。心理健康方面，GDS-15評估結果顯示；介入後憂鬱程度逐漸改善，不同時間點之差異亦達統計顯著（p＜.001）。廣義估計方程式分析結果顯示；在控制人口學背景變項後，時間效果仍具有統計顯著性，顯示居家復能介入對提升個案功能恢復及改善整體照護成效具有穩定且正向之影響。結論：出院準備服務銜接長期照護居家復能，可有效提升腦中風個案之日常生活功能、降低照顧管理需求，並改善憂鬱情形，顯示居家復能對促進功能恢復及提升生活自立能力具有良好成效。建議未來持續強化醫院出院準備服務與長期照護資源之無縫接軌，提升跨專業團隊合作效能，並及早提供個別化居家復能介入，以增進腦中風個案返家後之功能恢復、生活品質及照護連續性，作為未來長期照護服務規劃、臨床照護實務及相關政策推動之重要實證依據。AbstractBackground and Objectives: Stroke remains a primary cause of disability and long-term care needs among the elderly population in Taiwan. Upon discharge, stroke survivors frequently confront concurrent physical impairments and geriatric depression. This study aims to evaluate the empirical outcomes of transitioning from hospital discharge planning to community-based home-based reablement within the Framework of Long-Term Care (LTC) 2.0. By assessing its tangible impacts on delaying disability and alleviating depressive symptoms, this study seeks to provide localized, evidence-based clinical insights to support the transition toward "precision reablement" and "medical-nursing integration" envisioned in LTC 3.0. Methods: This study employed an intervention-based observational study with a quasi-experimental design. Stroke survivors meeting the inclusion criteria were monitored, with repeated measurements collected pre-, mid-, and post-intervention. Research instruments included the Ministry of Health and Welfare’s official Care Management Scale (CMS) and the Short-form Geriatric Depression Scale (GDS-15). The intervention protocol comprised individualized home-based reablement sessions delivered by a multidisciplinary team once a week, for 60 minutes per session, totaling 12 sessions over 3 months; the training encompassed five core dimensions, including muscle strength, balance, and respiration. Statistical analyses utilized Repeated Measures ANOVA and Generalized Estimating Equations (GEE) to address longitudinal data characteristics and potential missing values. Results: Following the 3-month intervention, participants demonstrated a significant improvement in their LTC need level (CMS), shifting from Level 4 to Level 2. Their functional status progressed from moderate-to-severe dependence to independence or mild dependence, with the most pronounced gains observed in "walking" and "transferring" on the Barthel Index. Regarding psychological outcomes, GDS-15 depression scores significantly decreased from 8 to 5 (p < 0.001), demonstrating an effective reduction in post-stroke depressive distress while simultaneously mitigating caregiver burden. Conclusions: This study empirically validates the seamless transition model of "care upon discharge, rehabilitation within the community." It is recommended that LTC 3.0 optimize the referral efficiency of hospital discharge planning and initiate early home-based reablement interventions to achieve the strategic goals of precision reablement and healthy aging in place.腦中風出院準備服務居家復能日常生活活動功能憂鬱StrokeDischarge Planning CareDisabilityDepression disorder.thesis