本研究的目的在探討出院病患對服務的滿意度、 家庭照護能力以及居家所面臨健康照護問題，樣本來自臺北市某醫學中心的七個病房，於個案出院後一週及一個月後均進行一次電話追蹤訪問，自 85 年 6 月起至 86 年 6 月底止，共收案 189 名。 結果發現：約九成的病患出院後返家，由家人照顧。約九成的主要照顧者執行照顧的能力為「中等或強」， 有 97.2 ％的人認為出院後適應情況為「尚可或很好」，89.7 ％的人對整體服務感到「滿意或非常滿意」。居家所面臨的健康照護問題，包括生理方面（出現不適症狀、日常活動受限制、傷口與各種導管的照顧問題、病情監控與複診安排不易）、健康照護之訊息來源不足（疾病控制概念訊息不足、藥物相關知識訊息不足、與疾病有關的生活適應訊息不足、如何運用社會資訊的訊息不足）及社會心理方面（情緒壓力大、面臨經濟困境）。大多數的問題在第一次追蹤時發現，在第二次追蹤時都有減少的趨勢。因此，醫療團隊應不斷修正其出院規劃，與社區維持良好的溝通與轉介管道，持續追蹤與指導，以增強病人自我照顧能力，以提昇病人生活品質。

　　　　　The purposes of this study were to understand the level of satisfactionwith services, family competence in caregiving and the problems of familycaregiving among discharged patients. The subjects were 189 discharged patientsfrom seven wards in a medical center. All of the subjects were interviewed bythe researchers by telephone. They were called in the 1st week and 4th weekafter discharge. The results showed that 90% of subjects resided at home andwere cared for by their families. About 90% of the caregivers had fair or goodcompetence in caregiving. 92.2% of the patients' level of adjustment was fair orgood. 89.7% of the subjects' level of satisfaction with services was good orvery good. The problems of family caregiving included: physical problems(uncomfortable signs and symptoms, limitations of the activities of dailyliving, difficulties in tube and/or wound care, difficulties in monitoring thedisease and arranging outpatient appointments), insufficient information abouthealth care (disease control, medication related issues, strategies for livingadjustment, utilization of social resources) and psychosocial problems(psychological distress, economic problems). Interventions during the firsttelephone cells were implemented, and the problems were decreased during thesecond calls. Therefore, members of the multidisciplinary health care teamshould modify discharge planning, maintain good coordination and referralchannels within the community,l give good guidance and support to patients, andincrease the competence of caregiving, in order to improve the quality ofpatients' life.