Medical team staff assess care plans during hospitalization and after discharge.
Provide disease-related knowledge and care guidance.
Provide referrals to in‑hospital resources, such as dietitians, respiratory therapists, rehabilitation therapists, social workers, home care nurses, palliative home care nurses, palliative co‑care nurses, and diabetes educators, etc.
Provide information on rental of medical equipment needed for home care.
Provide home medical services, such as for individuals with limited mobility or disabilities who have medical needs (home visit consultations, replacement of nasogastric tubes, catheters, tracheostomy tubes, wound care).
Coordinate long‑term care services: home care services, professional services (rehabilitative care, individualized service plan development and implementation, nutritional care, feeding and swallowing assistance, behavioral care, bedridden or long‑term activity support, home environment safety or barrier‑free space planning, home nursing guidance and consultation), transportation services, assistive device subsidies and home barrier‑free environment improvements, respite services, etc.
Assist with referrals and provide subsequent care institutions.
Provide related social welfare consultation.
After discharge, conduct telephone follow‑up care and provide medical consultation: medication adherence, dietary status, caregiving ability, timely follow‑up appointments, or necessary assistance in referring to relevant units.
National Armed Forces Kaohsiung General Hospital Discharge Preparation Service – Long‑Term Care Promotion Video
