The service targets patients with multiple chronic conditions, covering 12 major chronic diseases and smoking cessation care.
The case management team is dedicated to establishing an integrated chronic disease care model to address the growing challenge of multimorbidity. The unit consists of 16 professional case managers providing services across 12 major chronic diseases, as well as smoking cessation care. Through comprehensive assessment, individualized care planning, continuous follow-up, and resource integration, the team delivers high-quality, patient-centered, and continuous care. Case managers maintain bidirectional communication with physicians from various specialties and regularly participate in multidisciplinary meetings to enhance care coordination, efficiency, and strategic management of patients with comorbid conditions. In addition, the unit actively participates in initiatives led by the National Health Insurance Administration and the Taiwan Centers for Disease Control. SOP, quality monitoring mechanisms, and the PDCA cycle have been systematically implemented to ensure consistent care quality, promote continuous improvement, and strengthen integrated chronic disease management.
Focuses on common comorbidity patterns such as cardiovascular, renal, and metabolic syndrome–related conditions.
Develops cross-disease integrated identification and early intervention strategies.
Utilizes a case management information system to enhance cross-disease identification and follow-up efficiency.
Empowers all case managers with smoking cessation counseling skills, integrating cessation support into cross-disease care pathways.
In 2024, the total number of newly enrolled chronic disease cases reached 4,760.
The average number of patients actively managed in chronic disease programs was 18,640.
47.4% of heart failure patients showed improvement in HbA1c and fasting blood glucose levels.
The pre-emptive vascular access completion rate in chronic kidney disease patients reached 73.12%.
The HIV screening completion rate among tuberculosis patients was 100%.
Among high-risk chronic disease patients with LTBI, 47.02% initiated treatment.
Approximately 270 atrial fibrillation cases were identified annually among stroke patients, with 20.88% starting pharmacological treatment.
Smoking cessation rates among chronic disease patients were 37.14% at 3 months and 36.27% at 6 months.
Pre-emptive vascular access completion in end-stage renal disease reached 73.12%, reducing cardiovascular comorbidity risk and improving care safety.
All stroke patients received atrial fibrillation screening, with medication initiated to reduce recurrent stroke risk.
All tuberculosis patients completed HIV screening, reducing treatment delays and adverse outcome risks.
Through diversified education and proactive outreach, chronic disease patient satisfaction averaged 97% over three years.
Medical team satisfaction averaged 97.4% over three years, reflecting strong recognition of case managers.
Ranked among the World’s Best Hospitals 2024 by Newsweek.
Received the Global Network for Tobacco Free Healthcare Gold Award three times (GNTH 2024–2027).
Recognized as a “Friend of Diplomacy” for medical cooperation with Pacific partner countries.
Presented over 20 oral or poster presentations at international academic conferences.
This initiative significantly improved care integration efficiency and service consistency by optimizing cross-disease care pathways through standardized workflows and quality indicators.
Active participation in national reimbursement programs enhanced healthcare system performance and strengthened integrated chronic disease management.
Future plans include integrating artificial intelligence and telehealth to reinforce post-discharge care continuity and advance a patient-centered care model.
