台灣高齡人口比率在2021年底達到16.8％，推估2025年邁入成為超高齡（super-aged）社會，屆時老年人口比例將超過20%，快速增加的高齡人口將帶給醫療與社會相當大的挑戰。面對快速老化的社會，世界衛生組織與各國也紛紛提出高齡整合照護手法與策略，期待能延緩失能、延長健康餘命與提供有尊嚴的照護。因此，提出適合高齡長者的整合性照護模式，有其急迫與必要性。本研究目的將藉由產業現況與回顧，並藉由研究個案高雄榮總高齡醫學中心為例，提出完整與合適的高齡整合照護模式建議。
　　藉由回顧世界衛生組織提出的2021-2030高齡照護十年綱領與健康老化概念，並參考加拿大Acute Care for Elders（ACE)、美國Age-Friendly Health Care System – 4Ms及日本高齡社會照護經驗，來探討從社區端預防延緩失能、integrated care for older people（ICOPE)評估及周全性評估整合門診，到急性醫療時的急診友善照護及住院長者友善照護手法，及出院後整合式出院轉銜服務與長照連結等，藉由國外經驗，提出產業現況文獻回顧。
面對快速老化社會，輔導會提供過去超過30餘年的醫養合一照護經驗，於三家榮總成立高齡醫學中心，提出許多創新整合式照護模式。本研究將以高雄榮總高齡醫學中心為例，說明高齡醫學中心在高齡整合照護中擔任的角色和任務，以及面對高齡化社會所提出的高齡整合照護服務模式。
研究發現高齡友善服務模式可以從社區照護、急性醫療和長期照護三個層面進行發展，其中包括預防延緩失能和多重慢病管理、急診端和住院端的友善照護模式、連結急慢性醫療及建立整合式出院轉銜服務等服務。這些服務可以有效改善高齡照護環境現況，提供高齡整合照護模式參考。

The proportion of elderly population in Taiwan reached 16.8% by the end of 2021, and it is estimated that by the year 2025, Taiwan will become a super-aged society with the elderly population exceeding 20%. The rapid increase in the aging population, including the super-aged population, poses significant challenges to healthcare and society. In response to the rapid aging society, the World Health Organization and countries around the world have put forward various strategies and approaches for integrated care for the elderly, aiming to delay disability, prolong healthy life expectancy, and provide dignified care. Therefore, it is urgent and necessary to propose an integrated care model suitable for the elderly. This study aims to propose a comprehensive and appropriate integrated care model by examining the current industry situation, reviewing the case of Kaohsiung Veterans General Hospital's Center for Geriatric Medicine.
By reviewing the World Health Organization's Global Decade of Healthy Aging 2021-2030 and the concept of healthy aging, and referring to Canada's Acute Care for Elders （ACE), the United States' Age-Friendly Health Care System - 4Ms, and Japan's experience in aging society and care, this study explores various aspects, including preventive measures at the community level to delay disability, integrated care for older people （ICOPE) assessment and comprehensive evaluation in outpatient settings, emergency department-friendly care and inpatient-friendly care practices during acute medical care, as well as post-discharge integrated transitional care services and long-term care connections. By drawing on international experiences, the study presents a literature review of the current industry situation.
In the face of a rapidly aging society, the Guidance Institute has accumulated over 30 years of experience in integrated care, establishing three Centers for Geriatric Medicine in the Veterans General Hospitals and proposing innovative integrated care models. This study takes Kaohsiung Veterans General Hospital's Center for Geriatric Medicine as an example to illustrate the role and responsibilities of a geriatric medicine center in integrated care for the elderly, as well as the proposed service model for integrated care in an aging society. The study found that the age-friendly service model can be developed from three perspectives： community care, acute medical care, and long-term care. This includes preventive measures to delay disability and manage multiple chronic conditions, emergency department-friendly care and inpatient-friendly care models, linking acute and chronic medical care, and establishing integrated transitional care services upon discharge. These services can effectively improve the current environment of elderly care and provide references for the development of an integrated care model for the elderly.

論文審定書 i
誌謝 ii
摘要 iii
Abstract iv
目錄 vi
圖次 vii
表次 viii
第一章 緒 論 1
第一節 研究背景：台灣高齡長者與失能現況 1
第二節 研究動機：高齡化社會與失能人口快速增加下的衝擊 5
第三節 研究目的：建立台灣高齡整合照護模式 7
第二章 產業概況 8
第一節 台灣高齡長者的全民健康保險及長照2.0資源使用現況 8
第二節 世界衛生組織健康老化的因應策略 11
第三節 加拿大的長者友善照護模式 15
第四節 美國高齡友善照護模式 19
第五節 日本照護模式 21
第三章 研究方法 23
第一節 高雄榮總高齡醫學中心 23
第二節 優劣分析（SWOT） 24
第四章 研究結果 27
第一節 輔導會醫養合一經驗 27
第二節 高雄榮民總醫院高齡醫學中心的願景、角色與貢獻 29
第三節 高雄榮總高齡醫學中心SWOT分析結果 35
第四節 高齡長者社區照護：失能預防與多重慢病管理 37
第五節 高齡長者急性醫療友善照護模式與介入成效 42
第六節 從急性醫療到長期照護：整合性出院轉銜服務 53
第七節 高屏澎醫療區域輔導與醫療資源整合水平展開 58
第五章 結論與建議 59
參考文獻 63

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