自從1993 年台灣老人已經超過世界衛生組織所定7%老人國的標準，因此長期照護於台灣非常重要，而出院準備又為長期照護之一部份，可確認出需要持續照護之高危險群。高品質的出院準備計畫能夠於出院前訓練患者及家屬自我照顧的技巧，以減少患者的再入院率，和降低醫療成本。本研究即評值南部某醫院出院準備計畫，二手資料分析以回溯方式檢視2002 年1 月至2003 年6 月間346 位個案的出院準備計畫，以瞭解其健康狀況和目前情況，及37 位個案的自我照顧
能力和家庭支持功能。成果評值依照南部某大學醫院的評估工具，包括患者的健康狀況、目前情況、自我照顧能力、和家庭支持功能。研究結果顯示個案的健康狀況於一年間呈現顯著進步，且此進步不受性別和照顧者人數的影響。此外，內容分析患者目前的情況，結果如下：57.4％穩定續追蹤，15.1％失去連絡，11.3％死亡，8.7％再度入院，7.5%轉至私人醫院、公共衛生單位、護理之家、或居家照護。再者，37 位個案的進食、如廁、沐浴、移動、用藥、疾病瞭解、焦慮、
和溝通的自我照顧能力與家庭支持功能於一年間呈現顯著的進步，且此進步不受性別和照顧者人數的影響，僅患者的大、小便控制和穿衣自我照護能力無顯著地進步。

The population of elders in Taiwan has increased by over 7% since 1993 and fit the WHO criteria for an aging country. Long-term care thus is very important in Taiwan, and discharge planning is the part of long-term care for identifying high-risk cases that require continuing care. High quality discharge planning can train patients and their family members in self-care skills early before discharging the hospital; thus reduced hospitalization return rate and health care costs. The purpose of this study was to evaluate the discharge planning. Secondary data analysis was applied to examine 346 cases in discharge planning retrospectively from January, 2002 to June, 2003 to understand their health status and current situation, as well as the self-care abilities and family support function of 37 cases. The outcome data were evaluated by the assessment tool of a Southern University Hospital, including the patient’s health status, current situation, self-care ability, and family support function. The study results identified that the outcomes evaluation of the patient’s health status improved significantly during one year, but sex and the number of caregivers do not affect the improvement. Additionally, content analysis of the patients’ current status broke down as follows: 57.4% stable or follow up, 15.1% missing, 11.3 % dead, 8.7% re-hospitalized, and 7.5% transferred to other units such as local clinics, public health stations, nursing homes, or home care. Furthermore, self-care abilities and family support function such as feeding, toileting, bathing, moving, medicating, illness awareness, anxiety, and communication of 37 cases improved significantly within one year, but sex and the number of caregivers do not affect the improvement. Only the patient’s bladder and bowel control and self-care ability in dressing did not improve.