The Development and Designing the Guidelines for Construction of the Collaborative Transition Care System between Hospital Staff and Home Care Staff

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The objectives of this study was developmentand designing the guidelines for construction of the collaborative transition care system between hospital staff and home care staff.The data in each municipal with regard to the process of system designing was collected from the following sources: recorded minutes; interview with project members; attitude survey of workers. The data was qualitatively analyzed in terms of the events during the process and necessary matters. The following guidelines were developed: 1.Obtaining support of a project to hospitals, home care agencies and health care institutions in community, 2.Organizing representatives of the hospital, agencies into a project team, 3.Identifying the local problems in a transition care, 4.Sharing the problems on extended conferences of concerned people, 5.Producing transition care program that contains the goals of each role of hospital staff and home care staff ,6.Evaluating the newly launched program through trials.