從醫院延伸至社區的照護已是全球精神照顧的主流，協助病患與家屬度過出院的關鍵階段，需要
良好聯繫與眾多社區資源投入。出院準備服務是提供以個案需求為導向、連結醫院與社區、重視
醫療團隊分工與合作，以個案管理方式提供服務並追蹤評價照護成果。本文透過文獻回顧與實際
案例，呈現出院準備服務的實務執行面，分析精神病患出院常遇到的問題以及相關的介入處置。
透過加強病患與家屬對疾病的認識與管理、強化工作人員對家屬的支持形成醫療的聯盟、建立社
區照護與正向支持網絡、執行出院效益評值，出院準備服務可提供有效且持續性的醫療照護，協助病患早期出院、節省住院費用及天數，使醫療服務得以兼顧品質與成本。

Care extension programs that bridge hospitals into the community are today a mainstream compo-nent of psychiatric care around the world. Stronger linkages amongst community resources can help patients and their families transition successfully through the hospital discharge process and reenter the community. Discharge planning is a service that provides the needs-oriented care necessary to link the hospital and community. Such planning, handled in accordance with case management pro-cedures, focuses on medical team cooperation, follow-up services and recovery evaluation. Using a review of the literature and a real case study, this article demonstrates the practical use of discharge planning services, analyzes problems frequently encountered during the discharge process and related interventions. By increasing the proper disease management knowledge of patients and their families, strengthening staff support to families through the creation of “medical leagues”, establishing com-
munity care and better support networks, and implementing a discharge process evaluation procedure, discharge planning services may provide efficient and continuous medical care essential to prevent re-
admission, reduce hospitalization expenses, and strike a better balance between medical service qual-ity and cost.