老年病人於住院中透過政府「出院準備服務銜接長照2.0」轉介，可使病人出院時及時連結長期照顧資源。政策試行期發現病人需求與轉介率有較大落差，且作業無一致規範，故藉本品質改善計畫提升轉介率。本計畫採用階段性策略：（一）擬定明確的轉介需求條件及流程；（二）長照需求評估教育；（三）發展醫病共享決策（shared decision-making, SDM）流程、研發決策輔助工具（patient decision aids, PDA）並資訊化。結果長照轉介率由改善前平均3.90%，進步至改善後平均10.52%，進步率為169.74%。本計畫發展之「FACE（Function and Care Evaluation）」篩檢條件，可針對長照需求做一普篩；對於照顧決策困難個案，再使用SDM及PDA了解病人及家屬的想法，儘早做出院準備。本計畫最終將此兩大對策併入出院準備流程，並標準化。

Transferal through the “Discharge Planning Linked to Long-term Care 2.0 Project” during inpatient care can provide timely transition from discharge to long-term care service for older adults. When the policy began, a large gap between patients' demands and transfer rate was found and no standardized discharge process existed. Therefore, the aim of this quality improvement project was to increase transfer rate. A stepwise approach was implemented with the following methods: first, development of criteria to screen candidates suitable for long-term care transferal and setting the discharge planning process; second, educational programs for long-term care needs assessment; third, development of online shared decision- making (SDM) process and web-based patient decision aids (PDA). The result showed the transfer rate increased by 169.74%, from 3.90% (mean) before project implementation to 10.52% (mean) after project implementation. Using FACE (Function and Care Evaluation) criteria developed under this project could screen candidates for long-term care sensitively and consistently. For patients and/or caregivers having difficulty choosing discharge destination, we use SDM and PDA to better understand their concerns and do early discharge planning. These methods have been incorporated to the standardized discharge process.