在制度之間做自主： 需密集支持肢障者使用長照與個助服務 的經驗與制度比較分析
作者
中文摘要
「自主」在長照與障礙研究中皆具重要地位，但兩者建立在不同制度邏輯，較少研究比較其在實際服務中的實踐。本研究以「做自主」（doing autonomy）為分析架構，透過文獻分析及十位障礙者之
質性訪談，探討需密集支持之肢障者同時使用長照居家服務與障礙者個助時，其自主如何被制度、專業文化與服務互動共同形塑。研究發現，長照評估高度標準化卻缺乏充分解釋，使使用者難以理解失能等
級與給付的關聯，且派班、額度與項目制限制削弱其生活掌控；個助採時數制並以使用者協商為核心，較能支持日常生活連續性與自主，但亦受預算控管、跨制度扣抵及人力不足限制。兩種服務內容雖高度
重疊，服務邏輯與方式卻有明顯差異。多數受訪者支持制度整合，但強調應以充足給付、提升選擇權及服務方式朝使用者導向轉型為前提。本研究從使用者觀點呈現制度運作如何形塑「做自主」，補足長
照與障礙服務整合的經驗與理論缺口，並指出改革應兼顧給付水準、權力關係與專業文化，以建構支持障礙者自立生活的服務體系。
英文摘要
Autonomy occupies a central position in both long-term care research and disability studies, yet the two fi elds rest upon distinct epistemological foundations and institutional logics. Few studies have examined how these differing conceptions of autonomy are enacted within actual service systems. Using doing autonomy as the analytical framework, this study explores how autonomy is shaped by institutional design, professional cultures, and service interactions when high-support-need persons with physical disabilities simultaneously use Taiwan’s long-term care (LTC) home-based services and disability personal assistance
(PA) services. Drawing on literature analysis and qualitative interviews with ten participants, the study compares the two systems across three dimensions: assessment and allocation, service content and delivery, and prospects for system integration.
Findings show that LTC assessments are highly standardized and opaque, making it difficult for users to understand how levels and allocations are determined, and that strict scheduling and quota constraints further weaken users’ control over daily life. PA services off er greater fl exibility but remain constrained by budgetary controls, cross-system deduction rules, and workforce shortages, limiting the full realization of user direction. Although service content overlaps substantially between the two systems, service modalities differ markedly: LTC operates through task-based billing and home-bound service expectations, while PA relies on hourly arrangements and user negotiation, better supporting continuity across daily life activities. Most participants favored integrating the two systems but emphasized that meaningful integration requires adequate resource allocation, expanded choice, and a shift toward user-directed service cultures.
By foregrounding service users’ perspectives, this study illustrates how institutional arrangements shape the possibilities of doing autonomy and contributes empirical and theoretical insights to ongoing debates about LTC–PA integration. The fi ndings highlight the need for policy reforms that address benefit adequacy, power relations, and professional norms to build service systems capable of supporting disabled persons’ independent living.