Post-discharge patients needing home or long-term care.
Patients with rehab potential (e.g., stroke, neuro injuries, fractures, or frail seniors).
By 2025, Taiwan will enter a super-aged society, with Banqiao District in New Taipei City facing above-average aging and caregiving demands. As the first medical center in the city, Far Eastern Memorial Hospital delivers integrated elder care under the principle of “leaving no caregiver’s needs unmet.” Through a multidisciplinary team, the hospital links inpatient care with discharge planning, escorted discharge support, home-based medical care, post-acute care (PAC), long-term care, and community resources, ensuring seamless transitions from hospital to home. This whole-person, family-centered, and community-based care model enhances older adults’ functional independence, supports caregivers, and reduces readmissions. From 2022 to 2024, the program served 63,866 patients, assisted 5,924 individuals in accessing long-term care resources, and achieved the highest PAC referral volume and success rate among medical centers in northern Taiwan.
Initiate discharge planning and care needs assessment at the time of hospital admission, enabling early linkage to post-acute care (PAC), long-term care, and home-based medical services. 2.Integrate three-stage home-based medical care, PAC, and Long-Term Care ABC resources to create seamless transitions across healthcare, long-term care, and community services. 3.Implement escorted discharge services, including transportation and stair-climbing support, to bridge the “last mile” from hospital to home. 4.Deliver integrated care through multidisciplinary, cross-setting teamwork, ensuring whole-person, continuous, family-centered, and community-based care.
2022–2024年
Discharge Planning: 12,774 patients served annually; 1,185 assisted each year in accessing long-term care resources.
Community Integrated Care (LTC A-level Unit): 510 new cases served per year.
Post-Acute Care (PAC): 164 referrals annually; stroke referrals ranked highest among medical centers in northern Taiwan.
Home-Based Care: 433 patients served annually across home medical care, home nursing, and home palliative care.
Community Palliative Care: 153 service encounters provided per year.
Discharge Planning Coverage: 26.7% average annual service rate.
Referral to Long-Term Care: 14.4% of discharge planning cases referred.
Successful Long-Term Care Linkage: 94.7% referral success rate.
Post-Acute Care (PAC) – Stroke: 80% successful transition rate.
Post-Discharge Follow-up (Telephone): 90% follow-up rate.
14-Day Readmission Rate: 0.82%.
Discharge Planning Satisfaction: 99.9%
Home Service Case Satisfaction: 98.5%
Home Nursing Patient/Family Satisfaction: 99.8%
Home Easy Go Discharge Support Satisfaction: 97%
Long-Term Care A-Level Unit Satisfaction: 97%
Ensure seamless post-discharge care transitions
Reduce risk of care interruption at home
Enhance functional recovery and independence after discharge
Lower unplanned readmission rates
Increase patient satisfaction with care services
Strengthen patient and family sense of safety and trust
Support local care delivery and home-based end-of-life care
