Outline of Presentation 1. Overview of NHI payment system 2. Development of TwDRGs 3. Design of DRGs-based payment system 4. Implication and Conclusio

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1 DRGs Symposium in Korea,16 Dec., 2011 Introduction and design of DRGs and DRG-based Payment System in, Dr. P.H. National Yang-Ming University,

2 Outline of Presentation 1. Overview of NHI payment system 2. Development of TwDRGs 3. Design of DRGs-based payment system 4. Implication and Conclusion

3 Overview of the NHI payment system and Case-Payment Initiatives

4 Overview of NHI payment system Unit of Payment: Fee for Services: major unit of payment Case Payment :54 cases ( until 2009) Per diem payment: chronic mental beds, day care Capitation: ventilator-dependent patients (1998-), Family Physician Initiatives(2004-),capitation Initiatives (2011-) Pay-for-performance(2001-) Global Budget: Expenditure cap: dental care(1998-), traditional medicine(2000-), clinics(2001), hospitals (outpatient ESRD) (2002-) Expenditure target: all others (home care, mental community rehab. center, payment initiatives) (2002-)

5 Payment system reform strategies Macro Strategies (Σ PiQi) Global budget Control cost Motivation for reform Level of payment Unit of payment Micro strategies Reform unit/level of payment (e.g. DRGs) efficiency/quality

6 Why DRGs? not comparable comparable It s difficult to make meaningful comparison on resources consumption among hospital patients with different levels of severity under fee-for- services (FFS). DRGs enable making meaningful comparison, thus will facilitate better hospital management by improving the effectiveness/efficiency of health care 6

7 Defining the Products of a Hospital (Fetter,1991) Hospital Operation FFS Physician Orders DRG Input 人力 Labor 醫材 Materials 設備 Equipment 管理 Management Output 住院天數 Patient days 伙食 Meals 檢查 Lab procedures 手術 Surgical procedures 藥品 Medications. Products Natural delivery without complication Appendectomy without complicated Dx Hernia repairment Efficiency Effectiveness

8 Case Payment Initiatives(CPI) - First-stage stage (1995( ) :22 cases defined by procedures of DRGs without CC (FFS if with CC*) 1999: 28 new cases defined by APDRGs(ALL-Patient DRGs) Total 54 inpatient DRGs, 5 outpatient DRGs by 2009 *CC: co-morbidity and complication

9 Diagnosis-related Groups, DRGs Define hospital products based on patients rather than hospitals characteristics Patients with similar clinical conditions and resource use were classified into the same DRGs based on their diagnoses, procedures, age, gender, co-morbidity, complication, discharge status, etc. In 1983, DRGs were adopted by US Medicare program as basis of Prospective Payment System (DRGs-based PPS).

10 First-stage stage Case Payment Initiatives payment rule, Case definition: by procedures or AP-DRGs 2. Payment: lump-sum payment per admission, including physician fees. 3. Payment price set based on historical costs with appropriate adjustment 4 Outlier payment(ffs) : threshold varied by cases 5. Quality assurance : should meet minimal required services guideline 6. Readmission within 2 weeks: providers responsibility

11 Cost: First-stage stage CPI yielded promising results* roughly the same or slightly increase due to the payment adjustment (for under-paid surgical procedures Resource consumption significantly decreased Length of stay reduced 10% (max 40%) Cost of pharmaceutical products decrease 15% Cost of elective ancillary services decreased *Lee, YC & Yang, MC, Li, CC. Health Care Financing System in : Before and After Introduction of Case-Mix. Malaysian J. Public Health 5 (supp 2), 19-32, 2005

12 First-stage stage CPI yielded promising results Quality Comparable or even better than before % admissions follow guideline sig. increased ( provide standard care) Access: shifting and dumping: Code creep to FFS cases ( paid by FFS) Incentive to claim outliers (on FFS bases) Patient transfer sig reduce 40%,according to analysis of claim data. *Lee, YC & Yang, MC, Li, CC. Health Care Financing System in : Before and After Introduction of Case-Mix. Malaysian J. Public Health 5 (supp 2), 19-32, 2005

13 Development and application of DRGs and DRGs-based payment system

14 Why still need DRGsbased payment system under GB Global budget (GB) system do control costs yet may or may not change providers behavior, low conversion factors (of Fee Schedules) trigger providers to ask for more budgets. Incentive of FFS is against the objective of GB. The development of a national DRGs system will facilitate faster implementation of case payment system and improve the efficiency of health care provision.

15 Development and application of DRG (Tw-DRGs) Case definition: Tw-DRGs (modified from CMS DRG) Data: based on NHI claim data Weight: calculated based on historical claim data Weight adjustment: adjust for fee schedule change within 3 years

16 Development of Tw-DRGs First version :based on CMS DRGs (499 groups),2001 Second version, modify DRGs structure based on local clinical practice Modify DRGs based on statistic principle Cost/LOS of at least 75% pts exceed 1 day Third version: Modify DRG based on providers recommendation

17 DRGs Grouping Diagram inpatient cases DRG Classification system diagnoses mutually exclusive Procedures Discharge status Gender Age Weight 25MDC+PREMDC MDC (Major Diagnostic Categories) Organ System 1029 DRG(2011) DRG1 DRG2 DRG3 DRG4 DRG5 DRGn RW1 Relative Weight RW2 Grouping by procedures with similar resource consumption ümutually exclusive ümanageable üsimilar resource consumption in each DRG groupð small variance 17

18 The performance of Tw-DRGs -better than CMS DRG, APDRG Version number of DRG R-square Tw3.0** (payment adju Tw3.0 *(without Waiv Tw Tw Tw1.0 (CMS) *exclude waivers **exclude waivers and adjusted for level of hosptial payment

19 Tw-DRG: planning and implementation Case payment TwDRG,1.0 TwDRG, Tw-DRG rd amended Tw-DRG first stage phase-in Tw-DRG3.0 Tw-DRG second stage face in? 498DRGs 976DRGs 1, 029DRGs 969DRGs 1, 017DRGs 19

20 Objectives of DRGs-based payment system reform (2 nd stage CPI) To improve the efficiency Reduce waste To improve quality and effectiveness

21 Tw-DRG DRG-based Case Payment Initiatives Phased-in within 5 years, starting from 2010 Outlier paid by marginal cost (80%) Payment adjustment (add on): children (9-91%),levels of hospital(5-7.1%), hospital case-mix index (CMI,1-3%),remote areas(2%) new technology/device w brand new function Conversion factor of global budget applied to all cost except procedures, anesthesia, blood, pharmacist

22 Waivers Tw-DRGs umdc19 & 20(Mental illness) uprinciple diagnosis of cancer uprinciple and secondary diagnosis of AIDS, hemophilia or rare diseases ulength of hospital stay> 30 days uecmo(procedure code 39.65)cases upilot projects uinpatient hospice case uother cases excluded from global budget 22

23 Tw-DRG payment rates (2.5 Percentile of each DRG) Lower Threshold (91 percentile of each DRG) Outlier threshold FFS DRG Fixed payment =Relative weight(rw) Standard payment amount(spr) (1+basic treatment adjustment+children adjustment +CMI Adjustment+ Geographic Adjustment) SPR=37,230 in 2010 DRG Fixed payment +outlier payment = DRG RVU Outlier payment=costs exceeding outlier threshold * 80% 23

24 Tw-DRG Payment adjustment ubasic Fee adjustment reflect previous difference in payment rates of basic hospital service among different types of hospitals uchildren adjustment increase 15% ucmi adjustment Reflect patient severity ugeographical adjustment:2% Types of hospital Basic adjust. Reduce difference for each type of hospital Total Academic medical center 7.1% 7.1% Regional hospital 6.1% 6.1% community hospital community teaching hospital 3.2% 1.8% 5.0% Local hospital 0.0% 5.0% 5.0% Age adjustment notmdc15 MDC15 internal surgery medicine <six months 91% 66% 23% >six months, <2years 23% 21% 9% >2years, <=6years 15% 10% 10% CMI adjustment Adjustment rate 1.1<CMI 1.2 1% 1.2<CMI 1.3 2% CMI>1.3 3%

25 Comparison of case-payment initiatives (CPI) at first and second stages 2 nd stages (Tw-DRG CPI),2010- Case definition Tw-DRGs 1 st stage CPI, Procedures, APDRG Payment rule Fixed amount same Outlier 80% of cost (no limit) 60% of cost (set max. Percentage ) Waivers Payment adjustment Minimal requirement Quality monitoring Selected disease, LOS>30 days Level of hospital, CMI, remote area & children no Hospital and EMR Readmission rate, transfer, mortality w comorbidity and complication Level of hospital Remote area yes same

26 Phased-in plan of Tw-DRG payment system Time # of DRG (th MDC) % of cost as all DRG-base payment Cumulated cost % of cost as all admissions DRG* (now 164) 28.60% 28.60% 17.36% 2011 ( ) 18.00% 46.60% 10.97% 2012 ( ) 14.30% 60.90% 10.26% 2013 (PRE ) 2014 ( ) 21.40% 82.30% 12.97% 17.00% % 9.16% total 1017 DRG (now 1029) 100% 60.72% *49 cases which were paid by case before 2010 (22% admission,29% cost)

27 Implication Grouper: DRG system is never perfect, may adopt any existing system (MS-DRG, IRDRG, ARDRGs ) as starting point and modify it according to analysis of existing data as well as local practice. Separate DRGs with payment system Application of DRGs is not limited to payment, its development should rely more on scientific research than interference of interest groups Design of DRGs-based payment system usually reflect local practice/health care system and need more political consideration.

28 Implication Special consideration for Payment system Outlier payment Standard threshold or case by case Variation between different levels of hospitals (negotiation) Application of new technology or devices. Phased-in strategies Gradually increase percent of cost paid by DRGs is preferred (vs. select MDCs)

29 Conclusions Although global budget payment system (GB) has controlled costs, it is still necessary to reform the unit of payment system (such as DRGs) to provide incentive for hospitals to improve efficiency/effectiveness (or reduce waste) Preliminary results indicate reduction on the LOS, yet readmission rate also slightly increase. DRGs-based payment system has triggered hospitals to enhance management thru establishment of clinical pathway. Quality and effectiveness of care, though lacking of evidence now, can be improved in the long-run. BNHI need to monitor the quality of care and modify payment to reflect the use of new technology Bundle-payment may be necessary in the long-run.

30 Thank you very much for your attention

31 Claims filing, reviewing and monitoring of DRGs-based Payment system in Ming-Chin Yang National University, 31

32 Flowchart of Filing and Reviewing Claims Filing Reject Bug detection Should use DRGs but failed to use DRG Deny the Case Accept Administrative review Sampling Professional Review Profile Analysis Payment calculation approve

33 Principles of Filing and Reviewing To ensure the correctness of DRG coding Correct Dx/Proc Correct Dis. Classification Corr. DRG+ Med. Quality Hosp. ümd üdiagnosis Document ücoding staff ü High RW DRG Completeness of document üclaims staff ü Grouper Approve üprof. Rvw. ücoding Rvw. Sampling üprocedural Rvw. üprofile analysis BNHI

34 Claims Review-1 Necessity of admission and treatment Appropriateness of Diagnosis and treatment Accuracy of diagnosis and coding The review focused on: ü Whether Patient can be treated in Outpatient? If so, with or without stating the reason to be hospitalized? ü Clinical evidence to support the necessity of surgery? The review focused on: ü Claim filing of procedure follow the payment guideline or indications? The review focused on:drg Validation ü Reliability and validity of claim data ü rationality of procedure and coding? Upcoding? Creeping? 34

35 Claims Review-2 Cost shifting of inpatient Appropriateness of outlier payment The review focused on: ü Shifting? Against Tw-DRG payment rule? ü Utilization? Appropriateness of utilization, especially for outlier cases. 35

36 Claims Review-3 Stability of discharge status Appropriate quality of care The review focused on:quality assurance ü Appropriate discharge status? ü Unnecessary referral? ü Readmission/emergency? ü Inappropriate quality of care? such as:serious medical complications, Serious physiological or anatomical impairment, Significant disability, death etc. 36

37 Profile Analysis Case-Mix Index CC DRG Percentage High-Risk DRGs Highest-Volume DRGs Problematic Diagnoses Problematic Procedure Variation in Length of stay and in Charges 37

38 Four dimensions of monitoring DRG cases efficiency Cost shifting Patient shifting (accessibility) effectiveness 1. Changes in inpatient days 2. Difference between DRG payment and actual claims 1. Decreasing necessary services and quality of care 2. Cost shifting from inpatient to outpatient 1. Rejection of severe illness or unprofitable patient 2. Separate hospitalization into several times or inappropriate referral 1. Changes of outlier 2. Changes in severity of disease 3. Changes in readmission, emergency rate 38

39 Efficiency Monitoring Average length of stay(days) Average RVU per case Ratio of DRG RVU to actual RVU 39

40 Average length of stay MDC 2009 年 2010 年 1~4 季成長率 1~4 季成長率 00 合計 % % 02 眼之疾病與疾患 % % 耳鼻喉及口腔之疾病與疾患循環系統之疾病與疾患消化系統之疾病與疾患肝膽系統或胰臟之疾病與疾患骨骼肌肉系統及結締組織之疾病與疾患皮膚皮下組織及乳房之疾病與疾患內分泌營養及新陳代謝之疾病與疾患腎及尿道之疾病與疾患男性生殖系統之疾病與疾患女性生殖系統之疾病與疾患 % % % % % % % % % % % % % % % % % % % % 14 妊娠生產與產褥期 % % 40

41 Average RVU per case ( 合計 ) MDC 2009 年 2010 年 1~4 季成長率 1~4 季成長率 00 合計 45, % 45, % 02 眼之疾病與疾患 27, % 26, % 耳鼻喉及口腔之疾病與疾患循環系統之疾病與疾患消化系統之疾病與疾患肝膽系統或胰臟之疾病與疾患骨骼肌肉系統及結締組織之疾病與疾患皮膚皮下組織及乳房之疾病與疾患內分泌營養及新陳代謝之疾病與疾患腎及尿道之疾病與疾患男性生殖系統之疾病與疾患女性生殖系統之疾病與疾患 26, % 25, % 108, % 108, % 27, % 26, % 48, % 46, % 63, % 60, % 38, % 36, % 36, % 36, % 142, % 127, % 37, % 37, % 43, % 43, % 14 妊娠生產與產褥期 25, % 25, % 41

42 Ratio of DRG RVU to actual RVU ( 合計 ) MDC 2009 年 2010 年 1~4 季 1~4 季 00 合計眼之疾病與疾患耳鼻喉及口腔之疾病與疾患循環系統之疾病與疾患消化系統之疾病與疾患肝膽系統或胰臟之疾病與疾患骨骼肌肉系統及結締組織之疾病與疾患皮膚皮下組織及乳房之疾病與疾患內分泌營養及新陳代謝之疾病與疾患腎及尿道之疾病與疾患男性生殖系統之疾病與疾患女性生殖系統之疾病與疾患妊娠生產與產褥期

43 Cost Shifting Monitoring Average outpatient utilization of lab tests or diagnostic examinations one week before hospitalization Average outpatient utilization one week before Hospitalization Percentage of patient with CC 43

44 Average outpatient RVU of lab tests or diagnostic examinations one week before hospitalization ( 合計 ) MDC 2009 年 2010 年 1~4 季成長率 1~4 季成長率 00 合計 % % 02 眼之疾病與疾患 % % 耳鼻喉及口腔之疾病與疾患循環系統之疾病與疾患消化系統之疾病與疾患肝膽系統或胰臟之疾病與疾患骨骼肌肉系統及結締組織之疾病與疾患皮膚皮下組織及乳房之疾病與疾患內分泌營養及新陳代謝之疾病與疾患腎及尿道之疾病與疾患男性生殖系統之疾病與疾患女性生殖系統之疾病與疾患 % % 1, % 1, % % 1, % 1, % 1, % % 1, % 1, % 1, % % % 1, % 1, % % % % % 14 妊娠生產與產褥期 % % 44

45 Average outpatient utilization one week before hospitalization ( 合計 ) MDC 單位 : 點 / 次 % 2009 年 2010 年 1~4 季成長率 1~4 季成長率 00 合計 1, % 1, % 02 眼之疾病與疾患 1, % 1, % 03 耳鼻喉及口腔之疾病與疾患 % % 05 循環系統之疾病與疾患 3, % 3, % 06 消化系統之疾病與疾患 % % 肝膽系統或胰臟之疾病與疾患骨骼肌肉系統及結締組織之疾病與疾患皮膚皮下組織及乳房之疾病與疾患內分泌營養及新陳代謝之疾病與疾患 1, % 1, % 1, % 1, % 1, % 2, % 1, % 1, % 11 腎及尿道之疾病與疾患 7, % 7, % 男性生殖系統之疾病與疾患女性生殖系統之疾病與疾患 1, % 1, % % % 14 妊娠生產與產褥期 % % 45

46 Percentage of Patient with CC ( 合計 ) MDC 單位 :% 2009 年 2010 年 1~4 季成長率 1~4 季成長率 00 合計 11.98% 6.68% 16.40% 36.89% 02 眼之疾病與疾患 0.00% % 耳鼻喉及口腔之疾病與疾患循環系統之疾病與疾患消化系統之疾病與疾患肝膽系統或胰臟之疾病與疾患骨骼肌肉系統及結締組織之疾病與疾患皮膚皮下組織及乳房之疾病與疾患內分泌營養及新陳代謝之疾病與疾患腎及尿道之疾病與疾患男性生殖系統之疾病與疾患女性生殖系統之疾病與疾患 3.90% 15.73% 4.77% 22.31% 64.53% 5.68% 69.30% 7.39% 12.12% 7.93% 15.10% 24.59% 19.78% 6.00% 21.85% 10.47% 18.89% 6.54% 24.11% 27.63% 6.14% % 6.13% -0.16% 0.00% % % 2.82% 69.23% 32.62% 26.68% 8.06% 29.20% 9.45% 9.75% 4.17% 17.72% 81.74% 14 妊娠生產與產褥期 6.25% 3.48% 9.99% 59.84% 46

47 Accessibility Monitoring-Referral DRG Case Referral ( 合計 ) MDC 單位 :% 2009 年 2010 年 1~4 季成長率 1~4 季成長率 00 合計 11.98% 6.68% 16.40% 36.89% 02 眼之疾病與疾患 0.00% % 耳鼻喉及口腔之疾病與疾患循環系統之疾病與疾患消化系統之疾病與疾患肝膽系統或胰臟之疾病與疾患骨骼肌肉系統及結締組織之疾病與疾患皮膚皮下組織及乳房之疾病與疾患內分泌營養及新陳代謝之疾病與疾患腎及尿道之疾病與疾患男性生殖系統之疾病與疾患女性生殖系統之疾病與疾患 3.90% 15.73% 4.77% 22.31% 64.53% 5.68% 69.30% 7.39% 12.12% 7.93% 15.10% 24.59% 19.78% 6.00% 21.85% 10.47% 18.89% 6.54% 24.11% 27.63% 6.14% % 6.13% -0.16% 0.00% % % 2.82% 69.23% 32.62% 26.68% 8.06% 29.20% 9.45% 9.75% 4.17% 17.72% 81.74% 14 妊娠生產與產褥期 6.25% 3.48% 9.99% 59.84% 47

48 Outcome Measurement The percentage of cases under lower threshold or above fixed loss threshold Three-day emergency rate Fourteen-day re-admission rate after discharge from admission CMI value 48

49 Percentage of cases under lower threshold or above fixed loss threshold-1 Case: Appendectomy with CC % % % % % 8.0 % 6.0 % 9 7 全年 9 9 Q 1 ~ Q Q 1 ~ Q % 2.0 % 0.0 % 97 年 99 年 1~6 月 100 年 1~6 月下限上限個案幾何平均個案幾何平均個案幾何平均 DRG 中文名稱 RW 支付點數範圍臨界點臨界點數住院日數住院日數住院日複雜闌尾切除術, ,897 ~ 58,612 27, , 有合併症 / 併發症 49

50 Percentage of cases under lower threshold or above fixed loss threshold-2 Case: Total hip replacement without CC % % 8.0 % 6.0 % 9 7 全年 9 9 Q 1 ~ Q Q 1 ~ Q % 2.0 % 0.0 % 97 年 99 年 1~6 月 100 年 1~6 月下限上限個案幾何平均個案幾何平均個案幾何平均 DRG 中文名稱 RW 支付點數範圍臨界點臨界點數住院日數住院日數住院日髖關節再置換術, ,732 ~ 129,742 49, ,755 1, 無合併症 / 併發症 50

51 Three-day emergency rate ( 合計 ) MDC 2009 年 1~4 季 2010 年 1~4 季再急診率成長率再急診件數成長率再急診率成長率單位 :% 件再急診件數成長率 00 合計 1.60% 5.96% 7, % 1.70% 6.25% 7, % 02 眼之疾病與疾患 0.89% 43.55% % 0.82% -7.87% % 03 耳鼻喉及口腔之疾病與疾患 0.95% 7.95% % 1.00% 5.26% % 05 循環系統之疾病與疾患 2.83% 4.81% 1, % 3.04% 7.42% 1, % 06 消化系統之疾病與疾患 1.88% 3.30% 1, % 1.86% -1.06% 1, % 07 肝膽系統或胰臟之疾病與疾患 1.71% 7.55% % 1.83% 7.02% % 08 骨骼肌肉系統及結締組織之疾病與疾患 1.64% 3.80% 1, % 1.77% 7.93% 2, % 09 皮膚皮下組織及乳房之疾病與疾患 0.94% % % 1.24% 31.91% % 10 內分泌營養及新陳代謝之疾病與疾患 1.07% 22.99% % 1.11% 3.74% % 11 腎及尿道之疾病與疾患 4.21% % % 5.56% 32.07% % 12 男性生殖系統之疾病與疾患 5.13% 3.43% % 5.21% 1.56% % 13 女性生殖系統之疾病與疾患 0.89% 5.95% % 0.95% 6.74% % 14 妊娠生產與產褥期 1.10% 6.80% 1, % 1.19% 8.18% 1, % 51

52 Fourteen-day re-admission rate after discharge from admission ( 合計 ) 2009 年 1~4 季 2010 年 1~4 季單位 :% 件 MDC 再住再住院再住再住院成長率成長率成長率院率件數院率件數成長率 00 合計 2.33% -1.3% 11, % 2.61% 12.0% 12, % 02 眼之疾病與疾患 1.75% -4.4% % 1.80% 2.9% % 03 耳鼻喉及口腔之疾病與疾患 1.08% -10.7% % 1.09% 0.9% % 05 循環系統之疾病與疾患 6.37% -2.3% 2, % 6.74% 5.8% 2, % 06 消化系統之疾病與疾患 2.24% -0.9% 1, % 2.51% 12.1% 1, % 07 肝膽系統或胰臟之疾病與疾患 2.11% -13.2% % 2.69% 27.5% % 08 骨骼肌肉系統及結締組織之疾病與疾患 3.67% 0.3% 4, % 3.73% 1.6% 4, % 09 皮膚皮下組織及乳房之疾病與疾患 6.39% 4.2% % 7.08% 10.8% % 10 內分泌營養及新陳代謝之疾病與疾患 0.80% -4.8% % 0.99% 23.8% % 11 腎及尿道之疾病與疾患 7.43% -35.6% % 9.49% 27.7% % 12 男性生殖系統之疾病與疾患 3.69% -5.6% % 4.21% 14.1% % 13 女性生殖系統之疾病與疾患 1.11% 1.8% % 1.42% 27.9% % 14 妊娠生產與產褥期 0.45% -8.2% % 0.56% 24.4% % 52

53 CMI value ( 合計 ) MDC 單位 : 點 / 次 2009 年 2010 年 1~4 季成長率 1~4 季成長率 00 合計 % % 02 眼之疾病與疾患 % % 耳鼻喉及口腔之疾病與疾患循環系統之疾病與疾患消化系統之疾病與疾患肝膽系統或胰臟之疾病與疾患骨骼肌肉系統及結締組織之疾病與疾患皮膚皮下組織及乳房之疾病與疾患內分泌營養及新陳代謝之疾病與疾患腎及尿道之疾病與疾患男性生殖系統之疾病與疾患女性生殖系統之疾病與疾患 % % % % % % % % % % % % % % % % % % % % 14 妊娠生產與產褥期 % % 53

54 NHI Tw-DRGs Outcome 164 groups is implemented in It accounted for 17.36% of the total inpatient care expenses. Promoting the efficiency of medical services. DRG cases in 2010 the Length of days 4.60% compare with last year. Improving the medical care quality and curative effect (the clinical pathway) Three-day emergency rate and Fourteen-day re-admission rate after discharge from admission have small scale increase. We will continually pay attention to the situation of anyone discharge from hospital. 54

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Microsoft Word - 簡章.doc 社區衛生護理師認證考試 100 年考試簡章主辦單位 : 台灣護理學會聯絡地址 : 台北市大安區信義路四段 281 號四樓聯絡電話 :(02)2755-2291 網址 :http://www.twna.org.tw/ 1 簡章目錄社區衛生護理師認證辦法... 1 社區衛生護理