全人服務足甘心：一步一腳印的義大肺阻塞團隊照護

<p>肺阻塞(COPD)是一種慢性呼吸道發炎不可逆的阻塞性疾病，位居臺灣十大死因第9位，每年超過6千人死亡。肺阻塞疾病複雜度高，且常伴隨多種共病，影響生活品質。因此必須要是跨領域整合的照護團隊，才能提升肺阻塞病人的疾病認知與自我照護。</p> <p>義大肺阻塞照護團隊成立於2018年，集結了超過10種以上的職類、專科與行政管理部門，各司其職與專業合作，提供以病人為中心的個別化照護。本文分享團隊透過各項措施：困難照護個案家訪、基層醫療院所教育訓練、病友會暨民眾衛教活動舉辦及長照C據點講座等；期望由循序漸進的方式走出醫院進入社區，讓肺阻塞照護更趨完整，提升照護品質。</p> <p> </p><p>"Chronic obstructive pulmonary disease (COPD) is a chronic, irreversible obstructive airway disease. It is the ninth leading cause of death in Taiwan and has caused more than 6,000 mortalities annually. Due to its high complexity and frequent comorbidities, COPD significantly impacts patients’ quality of life. Therefore, an integrated, multidisciplinary care team is essential to enhance patients’ disease awareness and self-care capabilities.</p> <p>The E-Da COPD Care Team was established in 2018, bringing together professionals from over ten specialties, including clinical experts and administrative management personnel. Through collaborative efforts, the team provides patient-centered, individualized care. This paper shares various initiatives implemented by the team, such as home visits for complex cases, training programs for primary care institutions, patient support group activities, public health education events, and long-term care center lectures. By gradually extending services beyond hospital walls into the community, the team aims to enhance the comprehensiveness of COPD care and improve care quality.</p> <p> </p>