本文目的在於探討居家護理師在長期照顧的角色拓展，內文分別就居家護理服務對象、服務提供
者、服務內容、與成效指標逐一論述。居家個案屬性以高齡、合併兩種以上的慢性病、日常生活活動（ADL）與工具式日常生活活動（IADL）功能缺損、近期剛出院及獨居者，比其他個案更會去使用居家護理。健保居家護理給付方式引導照護模式的發展導致護理師偏重技術性照護為主，忽略心理、靈性、及社會層面照護。其次是資源連結與轉介能力不足，對弱勢個案的幫助受限，教育機構與專業協會培訓課程有必要因應目前的困境與研究發現作適當調整，以支持實務人員專業生涯的成長。

This article was developed to discuss the expanding role of home care nurses in long-term care. Home care recipients included in the study were elderly, had chronic illness conditions, were experiencing
ADL and IADL impairment, had been discharged from hospital, lived alone and tended to use home care services. Home care services funding from the National Health Care Insurance is limited to those clients with wounds, stomy, and indwelled catheters. Thus, home care nurses mainly provide technical care rather than care addressing psychological, spiritual and social needs. The present care model de-viates from the concept of holistic care. Besides, a lack of proper case management training and com-munity resources utilization constrains nurses from providing social care to the clients. The article can serve as a reference for education institutes and nursing professional association to justify relevant training programs in order to facilitate the professional development of home care nurses.