隨著人口老化，在急性醫療中常面臨急性病症療程結束，病患仍處於失能狀態，需要他 人照顧而無法出院返家。過去常以超長住院因應，形成出院困難之窘境。台灣健保署在民國 103 年始針對腦中風試辦急性後期整合照護計畫 (post-acute care, PAC)。PAC 計畫於民國106 年7 月擴大辦理，除原有腦中風及燒燙傷，更納入創傷性神經損傷、脆弱性骨折、衰弱高齡 及心臟衰竭等診斷。衰弱高齡的病人，在急性住院之後常常面臨急性功能下降，若能早期辨 識並及早介入，藉由PAC 計畫轉銜急性期和長期照護，將可降低病患失能的程度，減少機構 化，降低再住院率以及死亡率。

As population ages, many older adults suffer acute functional decline that persist after completing treatment course in acute care. They need care from others and are unable to return to their residences after discharge. In the past, this would lead to prolonged stays at hospital and difficult discharges from hospitals that create clinical dilemmas. In 2014, the Taiwan’s National Health Insurance Administration (NHIA) launched the first integrated Postacute Care (PAC) program for stroke patients. The target population has now expanded to include patients with burn injuries, traumatic nerve injuries, fragility fractures, heart failure, and frailty. Frail older adults often experience acute functional decline during hospitalization. It is crucial to recognize frailty and intervene early. By providing services that facilitate smooth transition between acute care and long-term care systems, the PAC program could not only decrease level of disability and prevent institutionalization, but also reduce re-admission and mortality rate.