目前醫療場域中，若要轉介病人接受其他專業照護，時機常是病人已發生了狀況。而全人照護理念是期待能以全生命週期與三段預防並重的立場，於良好的醫病關係中讓病人與家屬接受涵蓋生、心、社、靈面向之照護以利改善與提升疾病調適過程的生活品質。所以若要落實全人照護，讓各類照護策略的轉介被動性能增加更多主動介入之特色是可行途徑之一。本研究運用個案研究法，以治療年數在兩年內的肌無力病人為對象，探索目前現行方案對病人的意義與探索提升介入主動性的途徑。研究期間總計11 名病人參與，平均年齡48.5±10.6 歲，方案包括神經科醫師的醫療諮詢團體、精神科心理師的心理支持團體，以及肌無力病友志工提供的個別關懷服務。歷程分析發現三項方案特色分別和Erickson 的心理社會發展階段的社會角色相對應。所以也許從病人的需求揣摩其正處於何種心理社會發展階段，以適當相對應角色來規劃各類方案與掌握適當介入時機點，是能夠朝向落實全人照護的理念之途徑。

Patients are offered psycho-social interventions mostly after their problem happened. Based on the concepts of holistic health care, we can detect these obstacles first and prevent these to arise. This study tried to explore how to integrate all resources in this medical center to facilitate the quality of holistic health care for the patients with myasthenia gravis. We invited 11 participates, average age was 48.5±10.6 into 3 interventions- medical counseling group by the neurologist, psychological supportive group by the psychologist, and individual caring service by the peer volunteers. We found the characteristic in each intervention could be combined and represented psychosocial development. From psychosocial developmental point of view, it could be helpful to bridge different discipline-leading services into the holistic-health-care process.