Top > ご連絡など > ケアマネジャーの介護保険NEWS > 【介護支援専門員 NEWS】ケアマネ支援に包括配置 「地域連携推進員」とは
【介護支援専門員 NEWS】ケアマネ支援に包括配置 「地域連携推進員」とは
都はモデル事業で、看護師の有資格者を地域連携推進員として大塚地域包括支援センター(文京区)と小金井にし地域包括支援センター(小金井市)に配置。各センターからの報告を踏まえ、パネリストたちが意見交換を行った。
地域連携推進員の役割は、医療機関から退院する高齢者の情報を入手し、ケアマネジャーに対して特に医療系サービスの活用を助言、ケアプラン作成を支援する。また地域包括支援センターに配置されている保健師、社会福祉士などその他の専門職とも連携し、病院から退院する高齢者への個別支援のためのネットワーク形成を目的とし、医療機関や介護保険サービス事業者を訪問して「顔の見える関係づくり」を目指す。ときにはサービス担当者会議にも出席する。大塚地域包括支援センターの看護師を務める渡辺寿美氏は、高齢者が入院生活でどこまでADLが低下したか、退院後にどんな困難が起こるのか把握するための"退院・退所時情報シート"の書式を同センターで独自に作成し、介護保険サービスと地域の社会資源情報を整理しつつ、課題や情報をチームで共有する指針としたと述べた。また、主治医が家族に病状説明をする際に同氏が地域推進員として同席し、在宅での具体的な支援策を主治医に提案したことによって、患者の退院後も主治医と担当ケアマネジャーがスムーズに連携できたと語った。
小金井にし地域包括支援センターの保健師で、介護支援専門員資格も持つ荒井澄子氏は、骨折、糖尿病、脳出血などの「カンファレンス確認情報書」の書式を提示し、患者退院時に医療機関へ持参してケアマネジャーや病院の医療ソーシャルワーカーらとカンファレンスを実施したと報告。その会議結果も荒井氏がまとめてケアマネジャーらと共有したほか、ケアマネジャーと地域携推進委員がペアでクリニック同行受診などをしたと、現場に数多く足を運んだことによりタイムリーに情報共有できたと成果を語った。
また「ケアマネジャーがクリニック通院に同行したり、医師が在宅訪問をする際に同行する意義は非常に高いが報酬がつかないなど、医療サービスにくらべて報酬的に評価が低い」と課題をあげた。また「医療系出身ではない福祉系ケアマネも含めて、家族調整など多忙な業務もこなすケアマネに、すべての医療知識を求めるのは無謀だ」と擁護論を展開した。
文京区福祉部介護保険課地域包括担当係の石塚美佐子氏は、「地域包括支援センターの主任ケアマネジャーあてにアンケートを実施したことがあるが、医療と介護の連携を十分に意識しつつも、大病院を相手に二の足を踏むという声もあがった」と発言。
一方、大塚地域包括支援センターの渡辺氏は「福祉系のケアマネジャーだからというくくりには抵抗がある。自分は初めて地域連携推進員を引き受けるにあたり、ケアマネジャーの方が経験豊富だと思った。福祉系ケアマネであっても高齢者の生活を支えるうえで専門的な目で見て病院で意見をいうべきと思い、あえて私は一緒に行動はせず橋渡し役を意識した」と発言した。
コーディネーター役を務めた医療法人社団つくし会新田クリニック院長の新田國夫氏は、最後に「同じ看護師有資格者を配置した地域推進連携員の活動でも、働いてきた経歴や環境などによって、大塚地域包括支援センターと小金井にし地域包括支援センターでは微妙にスタンスの違いがある」とモデル事業を振り返った。
午前中からの長きにわたる講演・シンポジウムにもかかわらず、400名の参加者は閉会までほとんど席を立つこともなく、東京都民やケアマネジャーなど、東京都の地域包括ケアへの関心の高さがうかがえた。
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