針對出院後有後續照護需求者，醫師於住院期間召開跨領域專業團隊會議，尋求

針對出院後有後續照護需求者，醫師於住院期間召開跨領域專業團隊會議，尋求團隊共識並擬訂適當出院照護計畫，提升個案及家屬後續照顧能力，並由岀備個管師協助轉介後續照護資源。

結果 (英文) 1:

For follow-up care after discharge there is a demand, hospital physicians convened in cross-cutting professional team meetings, team seek consensus and to develop appropriate discharge care plan, to enhance the ability to take care of the follow-up of cases and their families, prepared by Chu tubes division to assist referral follow-up care resources.

結果 (英文) 2:

For those who have follow-up care needs after discharge from hospital, the physician holds a cross-cutting professional team meeting during hospitalization to seek team consensus and formulate appropriate discharge care plan, to enhance the case and family follow-up care capacity, and to be referred to follow-up care resources by a manager.

結果 (英文) 3:

For those who need follow-up care after discharge, the doctor will hold a cross domain professional team meeting during hospitalization to seek team consensus and draw up appropriate discharge care plan, improve the follow-up care ability of the case and family members, and provide a personal manager to assist in referral of follow-up care resources.