本單位原有之個案管理制度，經分析發現仍有改進空閒，加上病人再入院率偏高，故引發此專案動機。本專案之目的係應用個案管理模式早期發現病人出院後的照護問題及需求，訂定照護計劃，提供服務或安排轉介，使其能安心出院，藉由電話訪問達到持續照護之目的。專案實施過程分為準備期、執行期及評值期，實施後不僅提昇照護品質，並建立良好的護病關係。出院準備計劃之服務人數由原來31人增至74人，改善率為138%；電訪人數由31人增至253人，增加率為716%；出院準備服務整體滿意度，由專案前之2.8分提升至4.4分；單位病人再入院率由12.1%下降為4.5%。由此專案結果建議全院各單位宜積極推行出院準備服務及電話訪問，以提高服務品質及病人滿意度。

　　　　　Careful analysis has shown that case management in unit, has the potential to be improved in to reduce patient re-admission rates. The purposes of this project were to use case management to identify as early as possible the potential care problems and care needs of patients after discharge, to establish care programs, to arrange services and transfers, and facilitate efficient patient discharges. The project also provided sustainable care via telephone visiting. The project was divided into preparation, performance and evaluation phases. Our results showed that we not only improved the quality of nursing care, and the nursing-patient relationship, but that we also dramatically increased the number of patients following discharge planning (from 31 to 74, an increase of 138%), and telephone visiting (from 31 to 253, an increase of 716%). The rate of satisfactions with discharge planning increased from 2.8 to 4.4, and the re-admission rate decreased from 12.1% to 4.5%. Thus, we can see that discharge planning and telephone visiting are very important to improvements in service quality and the satisfaction of patients.