Care plan must focus on at-risk families

By Shen Chen-lan 沈政男

From Taipei Times

Not long ago, it was reported that after his wife and two mentally disabled sons died at home, an 85-year-old man surnamed Yang (楊), who has dementia, continued to live with their bodies for months in their home in New Taipei City’s Zhonghe District (中和).

The incident prompted calls for the city to increase community support for families in need and have authorities visit them more often.

However, authorities should make more of the limited resources they have and prioritize high-risk families.

The 10-year Long-term Care Plan 2.0 has since its inception in 2017 helped many families. The plan focuses on community care, mainly offering in-home and daytime care services, and in rare cases 24-hour services. Few families with members who have dementia or a disability can rely on the plan for services during the night, on holidays or in unexpected situations.

It is no wonder that such families think the plan’s resources are insufficient and hesitate to call its 1966 hotline when in need. Some families even refuse its services when social workers recommend it to them.

Social workers and agencies involved in care services use a set of criteria to assess what services are needed on a case-by-case basis.

Take for example Yang’s family: The father having dementia and his sons being mentally disabled means they already met two criteria.

However, the authorities failed to monitor their needs based on these two factors. It should be reviewed whether Yang’s case was registered on the plan’s dementia care platform and whether a case manager was assigned to him. If there was, how often did the manager contact the family? Did the manager visit them or contact them by telephone?

If a person refuses to be registered as a case under the plan, doctors and nurses can try to persuade their family to have them enrolled, as medical professionals are often seen as more trustworthy.

For example, during the COVID-19 pandemic, if a family feared that a visit to their home by the plan’s social workers might expose them to the disease, medical professionals would explain the preventive measures the visitors would take to put the family at ease.

As for people with mental problems, the public healthcare system mainly focuses on the risk of self-injury and injury to others, as well as addiction to drugs or alcohol and domestic violence.

Yang’s sons were not deemed a risk, so no frequent visits were scheduled.

In cases where people with mental problems cannot take care of themselves or develop physical health issues, the plan should provide services to them.

Yang’s case is a warning for Taiwanese society.

Should the plan remain limited to community care, or should it be expanded to include 24-hour care? More than 200,000 foreign caregivers work in Taiwan, indicating that many people rely on care services. For them, a few hours of care per day under the plan is not enough.

Had Yang’s family hired a foreign caregiver, the deaths could have been prevented.

However, could they afford the to pay NT$30,000 per month for such services?

The Long-term Care Plan 2.0 should focus on high-risk households, as the nation’s resources to monitor people in need are limited.

A larger share of resources should be assigned to such families. This would be more important than registering more cases in the plan’s database.

Shen Chen-lan is a physician.

Translated by Eddy Chang

【善用有限的照顧資源 優先關注高風險家庭】

新北發生老母死亡後，兩個身心障礙兒子也相繼離世，獨留失智老父伴屍數月的悲劇。事發後有人建議補強訪視人力與提升鄰里互助，其實根本之道是善用有限的照顧資源，優先關注高風險家庭。

「長照2.0」施行以來，確實幫助不少家庭，然而因為定位成社區照顧，只有居家服務、日間照顧與稀少的全日照顧（喘息服務），因此對於中重度失智失能的家庭來說，白天居服員來了，或者參加了日照活動，還有更長的夜間、假日與突發狀況，得不到幫助，因此難免有家屬認為幫助不大，而不願撥打「1966專線」，甚至拒絕社工提供的服務轉介。

高風險家庭的介入通常經由指標個案，而新聞中的家庭有精障兒子、失智老父兩個接觸點，應可形成雙重追蹤，結果卻是雙雙失效。最應檢討的是，失智老父有無納入失智照顧平台，安排個管師追蹤？頻率與方式（家訪或電訪）為何？如果收案被拒絕，可請個案的主治醫師或護理師幫忙勸說，因為家屬通常比較信任醫療人員。比如在疫情期間，家屬若擔心訪視人員帶來病毒，可就長照體系的防疫措施給予說明，讓他們安心。

至於精神病患的追蹤，目前公衛體系聚焦於自傷與傷人風險，或者藥酒癮與家暴，而新聞中的精障兒子剛好沒有，因此訪視頻率不高。其實若病患退化到自我照顧不能，或者有生理問題不會處理，應與長照體系接軌，引進照顧資源。

此一事件警示台灣社會，到底公共長照該侷限於社區照顧，或者逐步擴展到全日照顧？事實上，台灣目前仍有廿多萬外籍看護，代表這些家庭幾乎沒有使用「長照2.0」，就因為一天幾個小時的照顧服務，幫助有限。新聞中的家庭若有能力聘雇外籍看護，悲劇就可避免，問題是一個月三萬元薪資，他們能夠負擔嗎？

在追蹤人力與照顧資源有限的狀況下，應將高風險家庭列為照顧優先目標。以新聞中的家庭來說，八十多歲老母照顧三名精障與失智家屬，屬於極度脆弱的家庭，所有接觸案家的人員都應有「老母若有不測，其他三人也會受難」的危機意識，不管如何一定要把大量照顧資源投注下去，這遠比追求收案量的帳面數字更有意義。