Discharge Planning

The discharge planning team at National Taiwan University Hospital consists of doctors, social workers, nurses, and quality control/ medical management-related members from various medical departments. We also assign a dedicated nurse to provide the following: long-term care services, education on discharge plan, quality control management, and assistance for helping the discharge plan of special cases. 

The characteristic of our service is that we adopt the unit-base model to implement discharge plan. Through the cooperation among the doctors, chief nurse, nurses, and social workers, we directly provide tailored services according patients long-term care needs. We give information for self-care, referrals to long-term care facilities and phone assistance to patients after discharge. Direct communication and interaction among hospital nurses and staff from referred long-term care facilities enables successful referrals and transfers that result in continuous and consistent care after patients’ transfer to home visiting organizations or nursing homes, because our medical teams are more familiar with their situations. For high risk cases, ward nurses as care consultant conduct direct phone follow-up after discharge. They persuade patients to implementing self-care information and adapting life when they do phone follow-up. The nurses also learn more from the feedback of patients, thus they could improve their teaching when patients are in the hospital and achieve the goal of providing high quality discharge planning.​