Program Goals

• Target Patients: Focus on individuals with multiple chronic illnesses, frequent hospitalizations, and those requiring early rehabilitation, palliative care, or integrated resource management.
• Patient-Centered Model: Promote close collaboration between hospitals and community healthcare providers to ensure seamless and integrated care for patients.
• Cross-Specialty Integration and Disease Management: Strengthen management for patients with multi-morbidities, improve resource allocation, reduce redundant tests, shorten treatment timelines, and minimize waste.
• End-of-Life Palliative Care: Introduce palliative resources to bypass departmental and locational barriers, reducing unnecessary waiting times for terminally ill patients and ensuring timely, appropriate care.

Achievements and Development

• Dual-Attending Physician System: Collaborated with municipal hospitals (e.g., Yangming, Heping, Zhongxing, and Songde Branch), community healthcare networks, regional hospitals, and veterans homes (e.g., Taipei, Banqiao, Taoyuan, and Bade Veterans Homes) to establish an integrated care framework.
• Expansion to Additional Departments and Facilities: Extended transitional care services to general internal medicine, occupational medicine, clinical toxicology, and family medicine, while incorporating other branches and affiliated hospitals, such as Guandu Hospital, Taipei City Hospital-Duties- Yangming Branch , Keelung Hospital, and Kinmen Hospital.
• Performance Metrics: Successfully completed 270 cases in 2024, significantly improving care efficiency.

Telemedicine and Follow-Up Services

• Regular Follow-Ups and Telemedicine: Case managers conduct follow-ups within six months of discharge. For patients unable to visit in person, telemedicine consultations are arranged.
• Comprehensive Coverage: Expanded telemedicine services to cover 10 major chronic disease specialties, including cardiology and diabetes care, as well as home care patients.
• Streamlined Processes:

1. Patients can consult via phone or video, with family members or representatives picking up medications at the hospital using the patient’s insurance card.
2. For those unable to visit the hospital, online payments via the mobile app are supported, with prescription delivery to community pharmacies for a fully contactless experience.