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Community care professionals were asked to complete a questionnaire concerning individual disabled elderly people living at home for whom they were currently providing care services in 6 municipalities, where multi-disciplinary meeting had been held regularly. Six hundred and fifteen subjects were reported in this study. The multidisciplinary meetings brought better results in identification of the insufficient information on the subjects, assessment of their health and social care needs, and coordination of care services needed for them compared to the performance by one professional or meetings within one discipline. Although the period of coordination of the services was significantly longer in the multi-disciplinary meetings than in the other procedures, there was no significant difference in the period of assessment of the subject's needs between the types of the procedures. Therefore, it is suggested that the multi-disciplinary meetings play an important role in order to achieve an appropriate care management process. However, the role of coordinator of services become important to shorten the period of the coordination. In all the municipalities, public health nurses contributed to coordination of services. In the municipalities where cooperation between agencies was good, social workers and PTs or OTs as well as public health nurses mainly acted as the coordinator. By contrast, where few disciplines other than public health nurses coordinated services, there were some problems in cooperation between agencies. It is likely that there were some limitations of coordination of services only by public health nurses. That is to say, it is suggested that one or two disciplines like social workers and PTs or OTs besides public health nurses should take part of the coordinator depending on the clients' needs. (Jpn J Rehabil Med 1998; 35: 918-925) 要 旨: 在宅ケアスタッフに対し, 在宅障害高齢者 (615例) へのケアサービス提供過程に ついてアンケー ト調査を6自 治体で行つた. 対象高齢者の情報収集 ・確認やニーズ評価, ケア サービス調整は, 担当者あるいは担当職種内で行 うよりも他職種との会議で行った場合が良好 な結果となっていた. しかし, 他職種 との会議の場合, ニーズの評価期間は他の場合と有意差 は認められなかったが, サービス調整に要した期間は有意に長 くなつていた. サービス調整の 中心的役割を担つた職種は, 医療 ・保健 ・福祉の連携に問題を残す自治体では主に保健婦であ ったが, 連携の進んだ自治体では保健婦に加えPT・OTと 在宅介護支援センターのソーシャ ルワーカーが均等に役割を果たしていた. (リハ医学1998; 35: 918-925) 1998年5月18日 受付, 1998年10月12日 受 理 *1長崎 大 学 医療 技術 短 期 大 学部/〒852-8520長 崎 市 坂 本1-7-1 School of Allied Medical Sciences, Nagasaki University *2南小 倉 病 院 リハ ビ リテー シ ョン科/〒803-0861北 九 州市 小 倉 北 区篠 崎1-5-1 Department of Rehabilitation, Minami-Kokura Hospital *3国立 療 養所 長 崎 病 院 リハ ビ リテー シ ョン科/〒850-0823長 崎 市桜 木 町6-41 Department of Rehabilitation, National Nagasaki Hospital 918 Jpn J Rehabil Med VOL. 35 NO. 12 1998 在宅 ケアサー ビス提供過程 における関係スタ ッフの連携

Multi-disciplinary Teamwork of Community Care Staff in Service Provisions for the Elderly.