『個案管理』在出院準備服務算是新開發的服務模式，因應整個健保給付制度的轉型，在未來亦有可能規劃及訓練這樣的專業人力，以落實政策及有效發展此一服務模式。本院於八十五年度加入衛生署推廣的『慢性病患出院準備服務』三年實驗計劃，神經內、外科即為率先試行的單位之一。以往單位內都是由正、副護理長或較資深者擔任推動及執行出院準備服務的業務，執行狀況及成效也各有不一。九十年三月由醫品會舉辦了第一期「個案管理師訓練班」，培訓了第一批的個案管理師，依各專科屬性發展不同重點之個案管理模式。神經專科個管師共同組成了個案管理圈，承接推動出院準備服務之業務，本文將依組織結構、過程及結果三方面來介紹我們的工作概況、成效及展望。

　　　　　 『Case management』is a new model in discharge planning. In the future, it will be necessary to train and create new experts to develop this work. Discharge planning was an experimental program of the Department of Health. The Taipei Veterans General Hospital’s neurological wards were enrolled in 1996. The preparation was done by the head nurse or practician in the past. The process and outcome weren’t coordinated among the wards. The first『Case Manager Training Program』was held in a medical center in 2001. The case managers established their own case management models in their division. In neurological wards, the case managers got together as a group to promote discharge planning. I would like to introduce the organization、procession and outcome of our group.