臺灣博碩士論文加值系統

研究緣起：台灣與其他歐美先進國家有著截然不同的精神醫療發展史，尚未經歷過「去機構化」的過程，社區裡缺乏精神復健資源。支撐台灣精神病患長期收容的「玉里模式」，是否值得繼續維持，是重大影響精神病人權益的問題。
研究目的：以玉里醫院祥和園區為硏究對像，計算其營運成本。同時計算玉里醫院新收公務床病人來玉里之前的直接成本，並比較這些病人在健保慢性病房住院與在祥和園區住院的經驗。
研究方法：本研究以「多元研究」，結合量性與質性的研究方式，針對「慢性健保床」與「玉里模式－祥和園區」兩種不同的機構特性，分別測量嚴重、慢性精神分裂症病人，在兩種不同的機構所花費的直接成本，以及所主觀感受到的照護品質上的差異。
一、以2003年4月15日至10月31日，至玉里醫院長期收容的公務床病人為樣本，計算其在來玉里醫院前後所耗用的直接成本的差異。
二、針對2002-2003年至祥和園區長期收容的病人，扣除無法進行訪談者，進行健保慢性床與祥和園區照護品質的半結構式訪談。
研究結果：長期住院的病人，轉到玉里醫院的長期收容園區後，可顯著降低所耗用的直接成本。針對祥和園區病人的訪談則顯示，多數病人認為祥和園區的照護品質更勝於之前住院的健保慢性病房。訪談內容顯示，「自由」是影響病人決定哪一種治療模式較好時最重要的原因。
結論：祥和園區是某些病人「限制更少的選擇」，也可視為決策者決定精神醫療長期照護政策時的參照。祥和園區有限的養護費用，則會促成威權化、集體化的管理方式，影響到病人的自由與人權，是未來決策者規劃長期收容政策時應面
對的問題。

One difference in the development of the history of psychiatric medication in Taiwan, compared with other advanced Western countries, is that it has not run through the process of ‘de-institutionalization’. That is, the communities lack resource of psychiatric rehabilitation. Whether if the so-called ‘Yu-Li Model,’ which has sustained the long stay care of psychiatric patients, is worthy maintaining becomes a significant issue that causes great influences upon the right of the patients.
The aim of this research is to calculate the running cost of Hsiang-Ho Branch of Yu-Li Hospital, the current research object. The researcher calculates the direct cost before the Yu-Li Hospital accepts patients of the official-budgeted ward, and then compares the experiences of patients between staying in the chronicle ward paid by Health Insurance and Hsiang-Ho Branch.
Focusing on the different institutional characters of ‘the chronicle ward paid by Health Insurance’ and ‘Yu-Li Model─Hsiang-Ho Branch,’ the researcher combines qualitative and quantitative methodologies to measure the direct the cost spent on, and the subjectively-felt quality of care by the serious and patients of schizophrenia in the two institutions respectively. Firstly, the research takes the long stay patients of the official-budgeted ward whom the Yu-Li Hospital accepted during 15th, April and 31st, October, 2003 as the samples to calculate the difference of direct cost spent before and after they came to Yu-Li Hospital. Secondly, except for those unavailable, the researcher conducts semi-structured interviews with the long-term patients who stayed in Hsiang-Ho Branch during 2002 and 2003 on the qualities of care between the chronicle ward paid by Health Insurance and Hsiang- Ho Branch.
As the result, the researcher finds out that, after transferring to the long-stay care branch, the direct cost spent by long-term patients has decreased to a significant level. The interviews with the patients in the Hsiang-Ho Branch also reveals that the majority of the patients think the quality of care in the Hsiang-Ho Branch is better that the chronicle ward paid by Health Insurance where they stayed before. Among others, ‘freedom’ is the most important factor which the patients used to decide the better pattern of treatment.
The conclusion of this research is that, for some patients, the Hsiang-Ho Branch means ‘the choice of less limitation’. It can also become a reference of the decision makers to decide the long stay care policy of psychiatric medication. The limited care expense of the Hsiang-Ho Branch, however, accelerates authoritative and collective management, which may influence the freedom and human rights of the patients and becomes an issue that the future decision makers should face on planning the policies of long-stay care.

表格目錄…………………………………………………………………5
摘要………………………………………………………………………6
壹、前言
一、背景介紹……………………………………………………….9
二、研究目的與重要性……………………………………………11
三、名詞界定………………………………………………………12
貳、文獻探討
一、 去機構化運動的緣起與發展
（一）精神分裂症的本質與去機構化運動的興起………………….13
（二）最小限制選擇………………………………………………….15
（三）新長期收容、旅舍、支持性住所…………………………… 17
（四）去機構化運動裡的嚴重精神病患…………………………… 19
二、台灣慢性精神病患長期收容制度現況
（一）長期收容機構與床位數分析………………………………….22
（二）玉里醫院簡介………………………………………………….22
（三）祥和園區簡介………………………………………………….24
（四）全民健保精神科慢性病房的特質…………………………….26
三、成本與照護品質的測量
（一）成本與效果…………………………………………………. 28
（二）照護品質…………………………………………………… 29
四、空間與自由………………………………………………… 31
參、研究方法與材料
一、研究對象…………………………………………………….32
二、論文概念架構……………………………………………….33
三、研究工具…………………………………………………….34
四、資料蒐集方法……………………………………………….35
五、資料蒐集過程……………………………………………….36
六、統計分析…………………………………………………….38
七、質性訪談資料整理………………………………………….39
肆、研究結果
一、描述性分析
（一）基本人口學資料………………………………………40
（二）病人來玉里前就醫狀況………………………………41
（三）各種醫療服務每月住院與診療費用估算……………42
（四）來玉里前後藥費統計…………………………………43
（五）祥和園區營運成本估算………………………………45
（六）研究個案追蹤…………………………………………47
（七）公務養護床病患長期收容前後直接成本比較…… 47
二、「和園區的一天」訪談記錄…………………………… 49
三、照品質經驗訪談分析…………………………………… 51
伍、討論
一、研究限制……………………………………………… 58
二、成本計算上的問題…………………………………… 59
三、玉里模式存在的理由………………………………… 62
四、測量照護品質的方法………………………………… 64
五、土地與空間：玉里模式的特點………………………65
六、不自由與更不自由：台灣慢性精神病患的處境……66
七、追求更好照護品質的成本…………………………… 68
陸、結論………………………………………………………………70
柒、建議………………………………………………………………72
捌、參考文獻…………………………………………………………74
玖、附錄
一、祥和園區居民長期收容前後照護品質訪談大綱……… … 79
二、May’s Inventory of Patients Attitudes……. ……… 80
三、祥和園區居民長期收容前後照護品質訪談同意書……… 81
四、「祥和園區居民長期收容前後照護品質」訪談內容簡表82
五、公費養護床收治原則……………………………………… 83
六、祥和園區平面圖…………………………………………… 84
七、護理機構設置標準………………………………………… 85

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