post-acute elderly with functional decline or continuous care needs, dementia cases, patients requiring pre-discharge assistive devices, Southern Veterans system residents

Kaohsiung Veterans General Hospital (3,490 staff, 1,482 beds), led by Dr. Ming-Yueh Chou (Director, Geriatric Medicine Center) and Director Chi Wang (Nursing Department), built the "Seamless Transition Care" system. As Taiwan becomes the world's oldest country and 20-25% of elderly become functionally impaired after each hospitalization, the team built 5 innovations + 5 features. Innovations: (1) Long-term Care Integrated Service Center (established 2016/8/5, Taiwan-first single-window connecting acute medicine to LTC); (2) Discharge planning seamlessly linked to LTC (traditional 4 weeks → zero-delay pre-discharge dispatch); (3) LTC consultation window (one-stop, no registration, no appointment, no fee); (4) Seamless assistive device service (since 2017/6, devices on-site before discharge); (5) Holistic Medical Integration Platform (100% auto-referral, 100% discharge service screening, with patent). Five features: (1) Elderly-Friendly Healthcare with consecutive Model Awards; (2) Community LTC Strategic Alliance (56 community medical groups, 21 home care agencies, 44 home medical groups, 31 post-acute groups, 15 home services / 12 rehab / 4 day care contracted points, 28 residential institutions, 26 community care points—over 300 partners); (3) Dementia Integrated Care Model (Veterans Affairs system #1 nationally, 328 dementia beds—25.4% of national service; 781 cases in 2019/6); (4) Community Integration Service Center (Level A); (5) LTC Talent Training Center.

• Taiwan-first acute care to LTC integration

• Pre-discharge dispatch zero-delay (vs traditional 4 weeks)

• Holistic platform 100% auto-referral (with patent)

• Assistive devices on-site before discharge

• First demonstration model with Health Bureau

• 2 consecutive Elderly-Friendly Model Awards

• 3,490 staff, 1,482 beds

• 300+ community strategic alliance partners

• 328 dementia beds (25.4% of national)

• 781 dementia cases (2019/6)

• 100% discharge service screening

• LTC Talent Training Center

• Discharge dispatch reduced from 4 weeks to zero

• #1 dementia care in Taiwan

• 100% auto-referral of need cases

• Elderly-Friendly Model Award 2 consecutive years

• Disability/dementia prevention extends to community

• Evidence-based dementia integrated care

• Cross-team case discussion

• Standardized discharge plans

• Cloud information system integration

• Dementia care guidelines & textbooks

• National dementia care & teaching institution

• Holistic medical integration platform patent

• High public satisfaction

• High dementia family endorsement

• Improved patient peace-of-mind at home

• National Quality Medical Award recognition

• Wide media coverage

• Health Bureau audit "Distinguished"

• Taiwan-first acute-to-LTC integration

• Smart Medical Quality Award

• Green Building Label

• 25.4% of national dementia bed capacity

• Holistic platform patent

• National dementia care & teaching institution

• Leads Southern LTC network with 300+ partners

• National dementia care benchmark

• Healthcare staff training center

• Demonstration model with Health Bureau

• National-first in Veterans Affairs system

• Drives nationwide elderly-friendly model