一位剛確診多發性硬化症的45歲女性病情正趨於穩定，但目前雙下肢肌力為 0/5。她向護理師哭訴：「我單身，積蓄幾乎花光了，我根本不知道出院後怎麼負擔得起輪椅，或是怎麼出門買日常用品。」護理師應優先啟動哪一種跨領域團隊的轉介？
A 45-year-old female newly diagnosed with multiple sclerosis is stabilizing but currently has 0/5 muscle strength in both lower extremities. She cries to the nurse, stating, "I am single, my savings are almost gone, and I don't know how I'll afford a wheelchair or get groceries once I'm discharged." Which interdisciplinary referral is the most appropriate priority for the nurse to initiate?
- AOccupational Therapist (OT)職能治療師（OT）
- BPhysical Therapist (PT)物理治療師（PT）
- CSocial Worker / Case Manager✓ 正解社會工作者／個案管理師
- DPsychiatric Nurse Practitioner精神科護理師執業者
本題測驗出院準備服務與跨團隊轉介的優先順序。病患面臨的直接核心問題是「財務困境」與「社區資源取得困難」（無力負擔輔具與維持日常生活基本盤）。根據個案管理原則，社工師（Social Worker）或個案管理師正是專門負責評估病患社經史、申請醫療保險補助、協助安排輔具租借以及連結居家長期照護資源的關鍵角色。雖然病患下肢癱瘓絕對需要物理治療師（PT，選項B，著重於大肌肉群的步態與轉位訓練）以及職能治療師（OT，選項A，著重於日常生活功能訓練），但若沒有社工師解決基礎財務與離院設備取得的問題，其他的復健計畫皆無法順利在社區推動。選項D雖然病患哭泣，但這是面對重大人生變故的正常悲傷反應，目前主要源於實際困難而非精神疾病。
This question tests discharge planning and the prioritization of interdisciplinary referrals. The client's most immediate core problems are financial hardship and difficulty obtaining community resources (inability to afford assistive devices and to meet basic activities of daily living). Under case management principles, the social worker or case manager is the key role specifically responsible for assessing socioeconomic history, applying for medical insurance benefits, arranging rental of assistive devices, and connecting the client to home and long-term care resources. Although the client's lower-extremity paralysis will absolutely require a physical therapist (PT, option B, focused on large-muscle gait and transfer training) and an occupational therapist (OT, option A, focused on activities of daily living), without a social worker to resolve the underlying financial and equipment-access issues, the other rehabilitation plans cannot be successfully implemented in the community. Regarding option D, although the client is crying, this is a normal grief response to a major life event and is currently driven by practical hardship rather than psychiatric illness.
美國的出院轉介極度依賴 Case Manager，負責協調 Medicare/Medicaid 支付輪椅設備；台灣則由醫院的「出院準備中心」聯合社工師，輔助病患申請長照 2.0 補助及重大傷病卡，基本流程相似。