Elderly relative is hospitalized and about to be discharged, what's next? A look at discharge planning services connecting to long-term care
When an elderly relative is hospitalized and the doctor says they can be discharged, family members often feel unprepared and unsure of the next steps. "Discharge planning services" are proactive assessments conducted by hospitals, not applications initiated by families. Most hospitals have ward nurses and case managers screen patients within 24 hours of admission to determine if a referral is needed. The official goal is to complete the assessment 3 days before discharge and connect to long-term care resources within 1 to 7 days after discharge (previously often taking 14 to 21 days). Below is a summary of who gets referred, what resources are available, how costs are calculated, and what families can proactively do.
What are discharge planning services and who initiates the assessment?
According to Article 75 of the Medical Care Act and the Ministry of Health and Welfare, the nature and initiation of discharge planning services are as follows:
- Article 75 of the Medical Care Act stipulates that hospitals shall, upon the request of discharged patients, arrange appropriate medical settings and personnel and provide follow-up care. This is the legal basis for hospitals to provide discharge planning services.
- The current operation is part of the Ministry of Health and Welfare's "Discharge Planning Connecting to Long-term Care Services Program" (implemented since 2017, with 242 hospitals nationwide as of the end of 2025), supported by the NHI's "Discharge Planning and Follow-up Management Fee" to fund hospital case management staff.
- Assessment is typically initiated proactively by ward nurses and discharge planning case managers; families do not need to submit a separate application. For example, Kaohsiung Veterans General Hospital Tainan Branch states that assessment is conducted within 24 hours of admission by ward nurses and discharge planning case managers.
- Not every hospitalized patient is referred—this service is for patients identified by screening tools as having post-discharge care needs, not automatically activated upon admission.
Which elderly patients are referred? Common screening criteria
According to the screening criteria published by Kaohsiung Veterans General Hospital Tainan Branch, patients meeting any of the following conditions are more likely to be included in case management:
- A certain score on the "Discharge Planning Service Needs Screening Form" with loss of self-care ability.
- Presence of tubes at discharge, such as tracheostomy, nasogastric tube, or urinary catheter.
- Readmission within 14 days for the same condition.
- Living alone or unable to perform daily activities independently.
- Major or chronic diseases such as stroke or diabetes with post-discharge care issues.
- Need for referral to home nursing, nursing homes, or other institutions, or meeting long-term care admission criteria with needs requiring referral to a care management center.
What resources can discharge planning services refer to?
According to the Ministry of Health and Welfare and multiple hospital announcements, the resources and services that discharge planning can help connect include:
- The Ministry of Health and Welfare states that long-term care service connections cover at least three of the following: home services, home nursing, home rehabilitation, respite services, and simple assistive devices.
- Hospital assistance typically includes: teaching caregiving skills for home care, assisting in preparing post-discharge medical equipment (e.g., suction machines, nebulizers), assisting in home environment assessment and arrangement, assisting in social welfare resource applications and consultations, referring to home nursing or nursing homes/chronic wards, and post-discharge telephone follow-up care.
- For those with long-term care needs, hospital case managers refer to the local long-term care management center to connect subsequent long-term care 2.0 service assessments and applications.
- Most of these referrals are proactively arranged by the hospital; the family's role is mainly to cooperate with assessments and provide information about the elderly person's actual living conditions, rather than running around to apply on their own.
What is the timeline? How long from assessment to connecting to long-term care services?
According to the official timeline goals announced by the Ministry of Health and Welfare:
- The process includes five steps: assessment → application → referral planning → discharge → service initiation.
- The official goal is to complete the assessment 3 days before discharge to allow sufficient time for subsequent applications and referrals.
- The target for connecting to long-term care services after discharge is within 1 to 7 days, significantly shorter than the previous 14 to 21 days.
- Actual timelines vary depending on individual assessment results, local care management center scheduling, and family cooperation speed; not every elderly patient completes the process within a fixed number of days.
Are discharge planning services free? What can families do proactively?
Regarding costs and actions families can take, the following is summarized:
- The hospital's discharge planning assessment and case management are covered by the NHI's "Discharge Planning and Follow-up Management Fee" and are NHI-covered items, not out-of-pocket expenses for families.
- However, the actual long-term care 2.0 services used after referral (such as home services, assistive devices, respite services) are subject to current long-term care 2.0 payment and co-payment regulations and are not entirely free. Actual cost-sharing ratios should be based on official announcements and individual assessment results.
- If you feel that no proactive assessment or notification was given during hospitalization, families can proactively contact the ward nursing station or social work office to request a discharge planning case manager assessment or referral to the local long-term care management center.
- For long-term care needs, you can also call the 1966 long-term care hotline. However, cases referred through hospital discharge planning are typically directly coordinated by the hospital with the care management center, so families may not need to call 1966 separately.
FAQ
What are discharge planning services? Do family members need to apply?
Discharge planning services are proactive assessments conducted by hospitals under Article 75 of the Medical Care Act and covered by National Health Insurance (NHI) to help arrange post-discharge care resources. Most hospitals initiate screening within 24 hours of admission by ward nurses and case managers; families do not need to submit a separate application. If you feel that no proactive assessment was conducted during hospitalization, you can proactively contact the ward nursing station or social work office.
Does every hospitalized elderly patient receive discharge planning services?
No. According to hospital screening criteria, whether a patient is included in case management depends on factors such as assessment scores, presence of tubes (tracheostomy, nasogastric tube, urinary catheter, etc.), readmission within 14 days for the same condition, living alone or inability to self-care, and major chronic diseases like stroke or diabetes. It is not automatically activated upon admission.
What resources can discharge planning services help refer to?
According to the Ministry of Health and Welfare, long-term care service connections cover at least three of the following: home services, home nursing, home rehabilitation, respite services, and simple assistive devices. Hospitals also often assist with teaching caregiving skills, preparing medical equipment, assessing home environment, applying for social welfare resources, referring to home nursing or nursing homes, and arranging post-discharge telephone follow-ups.
How long does it take to connect to long-term care services after discharge planning?
According to the official goals announced by the Ministry of Health and Welfare, the process includes five steps: assessment → application → referral planning → discharge → service initiation. The goal is to complete the assessment 3 days before discharge and connect to long-term care services within 1 to 7 days after discharge, significantly shorter than the previous 14 to 21 days. Actual timelines vary depending on individual cases and local scheduling.
Are discharge planning services free?
The hospital's discharge planning assessment and case management are covered by the NHI's "Discharge Planning and Follow-up Management Fee" and are not out-of-pocket expenses for families. However, the actual long-term care 2.0 services used after referral (such as home services, assistive devices, respite services) are subject to current payment and co-payment regulations and are not entirely free. Actual costs depend on official announcements and individual assessment results.
If I wasn't notified about discharge planning services during hospitalization, is it too late?
No. Families can proactively contact the ward nursing station or social work office to request a discharge planning case manager assessment and referral to the local long-term care management center. For long-term care needs, you can also call the 1966 long-term care hotline. However, cases referred through hospital discharge planning are typically directly coordinated by the hospital with the care management center, so families may not need to call 1966 separately.
· This page is a neutral compilation of information for reference only, not medical, legal, tax, or admission advice. For actual regulations and services, please refer to official announcements from competent authorities and the institutions themselves.