全球皆面臨高齡化社會的來臨，產生慢性病盛行率有逐年上升的趨勢與醫療費用高漲的問題。台灣實施全民健康保險後，提高了就醫可近性。但多數醫療資源集中於大醫院，且大多以專科或急性照護為主，這使需要跨專科與跨層級醫療服務的慢性病族群無法獲得適當的連續性整合照護。為了改善片斷化的專科照護模式，健保局(現已改制為健保署)於民國92年試辦並於民國95年正式實施「家庭醫師整合性照護計畫」(簡稱家醫計畫)。
本研究目的為了解家醫計畫下，以糖尿病為例，醫療群如何進行資源整合與影響分級醫療的相關因素，以提升慢性病照護之效率與品質。所採用的研究方法為質性研究；研究架構為Wagner所提出的慢性疾病照護模式(Chronic Care Model, CCM)。本研究針對糖尿病照護進行分析，主要原因為糖尿病是台灣常見的慢性病，且由糖尿病引起的死因與相關費用已造成了沉重的疾病負擔。
結果發現家醫計畫的成果顯現在基層診所與合作醫院的連結增多，如上轉病人、教育訓練的機會以及健康促進活動的相關支援。然而在資源整合方面卻未達到預期目標，並未打破各醫療院所獨立運作的照護模式，導致目前基層照護的醫療資源仍不足。專科化的醫療環境與病人的越級就醫行為，造成重新找回基層醫療與社區定位，充分發揮各醫療層級的功能上，成效仍有限。建議未來在家醫計畫的基礎下，重新檢視現今糖尿病的照護現況，致力於提升民眾的健康知能，促進各醫療單位的協同合作，繼續朝資源整合的方向邁進。健保局應積極加強下轉政策的宣導，並改善民眾的就醫行為，提升基層診所糖尿病的照護率與照護品質。期盼有朝一日能真正落實家庭醫師制度，以達健保的永續經營。

Aging population has increased the prevalence of chronic diseases and medical care costs around the world. The implementation of Taiwan National Health Insurance has improved access to health care. However, disproportional medical resources have been allocated to hospitals, where health care models have been designed to treat acute illness and patients who require specialty treatment. The current care models have prevented chronic patients from obtaining care that meets their complex needs. In response to this challenge, Taiwan’s health authority introduced a pilot scheme in 2003, and in 2006 officially launched Family Doctor Plan.
The present project aims to investigate how community health care groups introduced by the Family Doctor Plan have integrated medical resources to improve the efficiency and quality of chronic care. In particular, the present research examines the performance and integration strategies of diabetes care. This study chooses to focus on diabetes because of its high prevalence and high burden of disease. A qualitative analysis was conducted through interviews with physicians within community health care groups. Wagner’s Chronic Care Model was applied in designing the interview questions.
The current research discovers that the Family Doctor Plan did not appear to promote resource integration. There is some evidence on cooperation between clinics and hospitals in terms of physician training and education and health promotion. However, the provision of care was in general fragmented under the Family Doctor Plan. Recommendations from this study are that, under the Family Doctor Plan promoting cooperation between medical professionals and resource integration may be necessary to improve diabetes care.

學位論文審定書 i
誌謝 ii
摘要 iii
Abstract iv
目錄 v
圖次 vii
表次 vii
第一章 緒論 1
第一節、 研究背景與動機 1
第二節、 研究目的及重要性 2
第二章 文獻回顧 3
第一節、 糖尿病流行病學與糖尿病共同照護網 3
第二節、 家庭醫師整合性照護計畫 6
第三節、 慢性病照護模式(Chronic Care Model, CCM) 10
第三章 研究方法 14
第一節、 研究設計 14
第二節、 研究參與者 16
第三節、 研究流程 16
第四節、 資料處理與分析 17
第四章 研究結果 18
第一節、 各診所之基本資料 18
第二節、 訪談結果 20
第五章 討論與結論 24
第一節、 研究討論 24
第二節、 研究結論 31
參考文獻 34
附件一 訪談大綱 41
附件二 訪談結果統整表 44

一、英文文獻
Bodenheimer, T., Lorig, K., Holman, H., & Grumbach, K. (2002). Patient self-management of chronic disease in primary care. JAMA, 288(19), 2469-2475.
Bodenheimer, T., Wagner, E.H., & Grumbach, K. (2002). Improving primary care for patients with chronic illness. JAMA, 288(14), 1775-1779.
Braillard, O., Slama-Chaudhry, A., Joly, C., Perone, N., & Beran, D. (2018). The impact of chronic disease management on primary care doctors in Switzerland: a qualitative study. BMC Family Practice, 19(1), 159.
Bronstein, J., Sen, B., Morrisey, M., Blackburn, J., Kilgore, M., Engler, S., & Smith, W. (2018). Assessing the Impact of Case Management on Medicaid Clients with Chronic Diseases. Social Work in Public Health, 33(4), 215-225.
Chiou, S.T., Lin, H.D., Yu, N.C., Hseuh, H.K., Lin, L.H., Lin, L.T., Chen, T.J., & Lai, M.S. (2001). An initial assessment of the feasibility and effectiveness of implementing diabetes shared care system in Taiwan--some experiences from I-Lan County. Diabetes Research and Clinical Practice, 54 (1), S67-73.
Coleman, M.T., & Newton, K.S. (2005). Supporting self-management in patients with chronic illness. American Family Physician, 72(8), 1503-1510.
Coleman, K., Austin, B. T., Brach, C., & Wagner, E. H. (2009). Evidence on the Chronic Care Model in the new millennium. Health Affairs (Millwood), 28(1), 75-85.
Chen, C.C., & Chen, S.H. (2011). Better continuity of care reduces costs for diabetic patients. American Journal of Managed Care, 17(6), 420-427.
Davy, C., Bleasel, J., Liu, H., Tchan, M., Ponniah, S., & Brown, A. (2015). Effectiveness of chronic care models: opportunities for improving healthcare practice and health outcomes: a systematic review. BMC Health Services Research, 15(1), 194.
Del Valle, K.L., & McDonnell, M.E. (2018). Chronic Care Management Services for Complex Diabetes Management: a Practical Overview. Current Diabetes Reports, 18(12), 135.
Grumbach, K., & Fry, J. (1993). Managing Primary Care in the United States and in the United Kingdom. New England Journal of Medicine, 328(13), 940-945.
Glasgow, R. E., Orleans, C. T., & Wagner, E. H. (2001). Does the chronic care model serve also as a template for improving prevention?. The Milbank quarterly, 79(4), 579-612, iv-v.
Hickman, M., Drummond, N., & Grimshaw, J. (1994). A taxonomy of shared care for chronic disease. Journal of Public Health Medicine, 16(4), 447-454.
Harris, M.F., & Zwar, N.A. (2007). Care of patients with chronic disease: the challenge for general practice. The Medical Journal of Australia, 187(2), 104-107.
Hudon, C., Chouinard, M.C., Dubois, M.F., Roberge, P., Loignon, C., Tchouaket, E., Lambert, M., Hudon, E., Diadiou, F., & Bouliane, D. (2018). Case Management in Primary Care for Frequent Users of Health Care Services: A Mixed Methods Study. The Annals of Family Medicine, 16(3), 232-239.
Lee, C. P., Chu, C. I., Wu, D. A., Fu, C. C., Li, J. C., Wang, Y. H., & Chen, H. D. (2007). Comparison of the diabetes regular care model and the "diabetes share care disease management" model in eastern taiwan. TZU CHI Medical Journal, 19(2), 66-73.
Lin, B.Y.J., Lin, Y.K., Lin, C.C. (2010). Partnership effectiveness in primary community care networks (PCCNs): A national empirical analysis of partners coordination infrastructure designs. Health Care Management Review, 35(3), 224-234.
Lin, B.Y.J., Lin, C.C., Lin, Y.K. (2010). Patient satisfaction evaluations in different clinic care models: care stratification under a national demonstration project. Health & Place, 16, 85–92.
Liau, C. Y., Lin, C. C., Lin, Y. K., & Lin, B. Y. (2010). Partnership disengagement from primary community care networks (PCCNs): a qualitative study for a national demonstration project. BMC health services research, 10, 87.
Lin, T. Y., Chen, C. Y., Huang, Y. T., Ting, M. K., Huang, J. C., & Hsu, K. H. (2016). The effectiveness of a pay for performance program on diabetes care in Taiwan: A nationwide population-based longitudinal study. Health Policy, 120(11), 1313-1321.
Nutting, P.A., Dickinson, W.P., Dickinson, L.M., Nelson, C.C., King, D.K., Crabtree, B.F., & Glasgow, R.E. (2007). Use of chronic care model elements is associated with higher-quality care for diabetes. The Annals of Family Medicine, 5(1), 14-20.
Runyan, J.W., Jr, Phillips, W.E., Herring, O., & Campbell, L. (1970). A program for the care of patients with chronic diseases. JAMA, 211(3), 476-479.
Roland, M., Guthrie, B., & Thome, D.C. (2012). Primary medical care in the United kingdom. Journal of the American Board of Family Medicine, 25 (1), S6-11.
Siminerio, L.M., Piatt, G., & Zgibor, J.C. (2005). Implementing the chronic care model for improvements in diabetes care and education in a rural primary care practice. The Diabetes Educator, 31(2), 225-234.
Stellefson, M., Dipnarine, K., & Stopka, C. (2013). The Chronic Care Model and Diabetes Management in US Primary Care Settings: A Systematic Review. Preventing Chronic Disease, 10, E26.
Wagner, E.H. (1998). Chronic disease management: what will it take to improve care for chronic illness? Effective Clinical Practice, 1(1), 2-4.
Wagner, E.H., Austin, B.T., Davis, C., Hindmarsh, M., Schaefer, J., & Bonomi, A. (2001). Improving chronic illness care: translating evidence into action. Health Affairs (Millwood), 20(6), 64-78.
 
二、中文文獻
余儀呈(2008)。由慢性病照護模式看基層診所的未來發展(4)--決策支援的應用。醫療品質雜誌，2(2)，86-92。
李洮俊(2015)。由糖尿病共同照護網及健保局糖尿病醫療服務改善方案談基層糖尿病照護。中華民國糖尿病衛教學會會訊，11(2)，2-7。
李翠玲（2005）。民眾對「家庭醫師整合性照護計畫」知識、態度及行為之探討--以社區醫療群糖尿病人為例。高雄醫學大學公共衛生學研究所碩士在職專班碩士論文，高雄市。 取自https://hdl.handle.net/11296/y4m6uk
李曉伶、吳肖琪（2013）。台灣慢性病人醫療利用之探討－以慢性腎臟病、糖尿病及高血壓為例。台灣公共衛生雜誌，32(3)，231-239。
林宜璇（2009）。評估「全民健康保險家庭醫師整合性照護計畫」的實施對民眾醫療資源利用之影響。國立陽明大學醫務管理研究所碩士論文，台北市。 取自https://hdl.handle.net/11296/835sq8
林玟娟、黃志富、盧相如、張家禎(2012)。基層醫師對實證醫學的態度與應用之初探分析。醫療品質雜誌， 6(5)，59-65。
林俐伶、林秋菊(2016)。糖尿病整合照護之概論。護理雜誌，63(5)，115-120。
林恆慶、吳傳頌、許佑任、陳楚杰(2005)。台灣基層醫師對家庭醫師制度的認知、態度及認可之模式。台灣家庭醫學雜誌，15(1)，11-24。
施家嫻、李洮俊(2018)。從家庭醫師整合性照護計畫談糖尿病整合性照護。臺灣醫界，61(8)，24-29。
徐愫萱、賴韻如、葉琬喻、邱泰源,、陳慶餘、郭斐然 (2012)。以實證醫學回顧全民健康保險家庭醫師整合性照護計畫之成效。台灣家庭醫學雜誌，22(1)，11-24。
張必正、郭斐然、李汝禮,、王三郎、陳慶餘、邱泰源(2011)。台灣家庭醫師整合照護計畫的執行成效與未來展望。臺灣醫界，54(8)，56-60。
許碧升(2004)。醫師對「全民健保家庭醫師計畫」表現指標看法與評估結果之相關性研究-以高屏地區參加計畫醫師為例。高雄醫學大學公共衛生學研究所碩士在職專班學位論文，高雄市。取自華藝線上圖書館系統。（系統編號U0011-2903200614002121）
陳怡蒨（2007）。「全民健保家庭醫師整合性照護試辦計畫」對照護持續性之影響。國立陽明大學醫務管理研究所碩士論文，台北市。 取自https://hdl.handle.net/11296/yu26vt
陳麒丞（2005）。參與家庭醫師整合性照護計畫之民眾與醫療機構之成效評估。中國醫藥大學醫務管理研究所碩士論文，台中市。 取自https://hdl.handle.net/11296/9538qb
詹才興（2005）。以質性研究探討基層醫師對家庭醫師整合性照護試辦計畫之看法及執行現況。國立臺灣大學醫療機構管理研究所碩士論文，台北市。 取自https://hdl.handle.net/11296/udk8wj
詹其峰、邱泰源、陳慶餘(2013)。臺灣三全健康照護模式。臺灣醫界，56(2)， 51-56。
潘芷昕（2014）。家庭醫師整合性照護計畫對醫療照護利用與結果之影響。國立臺灣大學健康政策與管理研究所碩士論文，台北市。 取自https://hdl.handle.net/11296/gd6mp2
顔似綾、詹其峰、梁繼權、邱泰源、劉文俊、陳慶餘(2008)。社區醫療群家庭醫師對全民健保家庭醫師整合性照護試辦計畫政策滿意度調查。台灣家庭醫學雜誌，18(1)，11-21。
宋松遠、張慧如、陳銘樹、錢慶文(2007)。全民健保家庭醫師整合性照護制度試辦計畫之評估－以花蓮某社區醫療群為例。醫務管理期刊，8(1)，51-66。