背景 : 由於護理人員在運用篩選表，評估出院準備服務對高危險群之篩選個案人數，與個案管理師間有相當大的落差。 ' 目的 : 本專案目的在於探討與分析問題，規劃改善計畫以降低此落差。 方法 : 專案的進行係採實地觀察、與護理人員訪談，並設計問卷探討護理人員對篩選表之適用性及高危險群篩選查核表使用之看法，以確認落差形成之原因，據此加以分析、檢討，擬定改善對策。改善策略包含，規劃與執行出院準備服務相關之在職教育課程、修訂出院準備服務手冊與修正高危險群篩選表單。 結果 : 經專案介入措施實施後，護理人員與個案管理師篩選病患人數差異由 45.9%降至 6.7%，點選出院準備服務數位學習網站之點選率增加至 89.8%。顯示本項專案計畫，可促進護理人員對高危險群篩選之能力，有效提升出院準備服務中，對高危險群病患篩選之準確性，並進而增進對出院病患的照顧品質。 結論／實務應用 : 本專案改善計畫提供未來其他醫院於病房推動出院準備服務種子訓練之參考，使得出院準備服務層面更寬廣，醫療資源可更有效地被運用。

Background: High risk population numbers measured by nursing staff differ greatly from those measured by case managers due to differences in screening approaches used in discharge planning services. Purpose: This project intended to identify and analyze the relevant problems and develop an improvement plan to reduce the discrepency. Methods: The authors observed the clinical situation, interviewed nurses, and designed a questionnaire to evaluate the suitability of a designed screening table to collect nurses’ opinions on a high risk population checklist. Based on collected data, we identified and analyzed the cause of the gap, then revised current measurement tools to improve efficacy. Results: Strategies included providing in-service education related to discharge planning for nurses, revising discharge planning manuals, and re-developing the screening scale for high-risk populations. After implementation of the intervention, the difference of screening the high risk population between nursing staff and case manager decreased from 45.9% to 6.7%, and the hit rate on the discharge planning page on the e-learning web site increased to 89.8%. Conclusion / Implications for practice: Results showed that interventions enhanced nurse capabilities in screening high risk populations in the ward, and effectively elevated the accuracy of screening high-risk patients in discharge plans, thus elevating outpatient care quality. This project is suggested as a reference for hospitals developing training programs for discharge planning seed nurses in the wards. Once completed, these nurses can help expand the scope of discharge service to ensure medical resources are used more effectively.