台中市某精神復健機構中工作訓練階層配置與分級變動之相關因素探討

Abstract

隨著精神復健理念由疾病控制逐步轉型為強調功能恢復與社區融合的「復元導向」模式，工作復健訓練已成為協助精神疾病患者重返社會的重要策略。目前多數精神復健機構雖實施層級性訓練制度，但各單位多自行訂定工作訓練階層，缺乏統一標準與實證基礎，致使實務安置準則與個案職能狀況之間存在落差，且缺乏動態追蹤與進展評估機制。基於此背景，本研究以台中市某精神復健機構為對象，旨在探討其「三階五級」工作復健訓練模式下，個案訓練階層的初始配置與歷程中的等級變動情形，並進一步分析相關背景因素與預測指標。 本研究採回顧性量化設計，分析該機構2019年至2024年間累積之次級資料。資料來源包含個案基本人口學資料、精神疾病診斷、藥物自主管理評估結果及歷次工作訓練階層紀錄。研究將訓練紀錄轉為長格式，並依個案收案時間建立觀察期，彙整後總樣本為156人。研究首先分析個案背景條件與初始階層配置之對應情形，其次篩選出收案滿一年（12個月以上）的125位個案，評估其階層變動類型（升級、降級、不變）與變項關聯性。最後，建立邏輯斯迴歸模型以預測升級可能性。 研究結果顯示，訓練階層的初始配置與個案的收案時長、診斷類別及初始藥物自主管理等級具統計顯著關聯，顯示機構主要依循功能條件與穩定性進行訓練安置判斷。在125位有效樣本中，約4%的個案出現階層變動，多數個案階層維持穩定。升級者普遍具有年齡較輕、原始階層較低與病程較短等特徵。邏輯斯迴歸分析進一步證實，初始訓練階層為升級的最顯著預測因子（B = 10.963, p = .007），且當時病程亦為顯著負向預測因子（B = -0.312, p = .014）。模型整體辨識能力良好（ROC曲線下面積 AUC = 0.894）。此結果凸顯訓練初始配置與個案後續職能發展的高度關聯，並強調病程對復健進展的影響，指出訓練起點選擇與早期介入對整體復健成效的重要性。 綜合而言，本研究發現目前實務操作中的工作訓練階層安排大致與個案條件相符，但仍欠缺標準化配置準則與制度化追蹤指標。建議未來建構結合精神症狀、初始藥物自主管理等級與功能評估的實證分級安置準則，並強化訓練歷程之數據化監測，以提升訓練配置準確性與資源分配效益，進而促進精神障礙者之職能發展與社會參與機會。

As the paradigm of psychiatric rehabilitation evolves from disease control towards a"recovery-oriented" model emphasizing functional restoration and community integration, vocational rehabilitation training has become a crucial strategy to help individuals with mental illness re-engage with society. While most psychiatric rehabilitation institutions currently implement tiered training systems, the lack of standardized criteria and empirical basis often leads to discrepancies between practical placement guidelines and clients' actual vocational capabilities. Furthermore, there is a general absence of dynamic tracking and progress evaluation mechanisms. Against this backdrop, this study, conducted at a psychiatric rehabilitation institution in Taichung City, aims to explore the initial allocation of clients to training tiers and the dynamics of level changes within its"three-tier, five-level" vocational rehabilitation training model, further analyzing related background factors and predictive indicators. This study adopted a retrospective quantitative design, analyzing secondary data accumulated by the institution between 2019 and 2024. Data sources included clients' basic demographic information, psychiatric diagnoses, medication self-management assessment results, and historical vocational training tier records. Training records were transformed into a longformat, and an observation period was established based on each client's enrollment date. The total sample comprised 156 individuals. The study first analyzed the correspondence between client background characteristics and initial tier allocation. Subsequently, a subsample of 125 clients with over one year (12 months or more) of enrollment was selected to evaluate their tier change types (upgrade, downgrade, no change) and the associated variables. Finally, a logistic regression model was constructed to predict the likelihood of upgrade. The results show that theinitial allocation of training tiers is significantly associated with the client's duration of enrollment, diagnosis type, and initial medication self-management level, suggesting that the institution's placement decisions are primarily guided by functional conditions and stability. Among the 125 valid cases, approximately 4% experienced a tier change, with the majority of clients remaining at a stable tier. Upgrading clients generally exhibited characteristics such as younger age, a lower initial tier, and a shorter illness duration. Logistic regression analysis further confirmed that the initial training tier was the most significant predictor of an upgrade (B=10.963,p=.007), and that current illness duration was also a significant negative predictor (B=−0.312,p=.014). The model demonstrated good overall discriminative ability (Area Under the Receiver Operating Characteristic Curve, AUC = 0.894). These findings highlight the strong correlation between initial training placement and subsequent vocational development, emphasizing the impact of illness duration on rehabilitation progress and underscoring the importance of training starting point selection and early intervention for overall rehabilitation effectiveness. In summary, this study found that current vocational training tier arrangements in practice largely align with client conditions, but there is still a need for standardized allocation guidelines and institutionalized tracking indicators. It is recommended that future efforts focus on developing evidence-based tiered placement guidelines integrating mental symptoms, initial medication self-management levels, and functional assessments. Furthermore, strengthening the data-driven monitoring of the training process is crucial to enhance the accuracy of training allocation and resource utilization efficiency, thereby promoting the vocational development and social participation opportunities for individuals with mental disabilities.