本文以實務應用導向針對出院準備服務資源投入主要以年滿65 歲以上入院至出院以及即將要出院者為服務對象，在高齡失智長者就醫後，臨床工作者如何協助其順利轉至另一個照護環境，以確保出院後能獲得持續與良好的健康照顧服務，進而讓家屬減輕照顧負荷。研究結果顯示：在高齡失智長者接受所規劃的出院準備服務流程之建置，先參照原則、照顧需求及服務內涵後擬定初步流程為：(1)改善出院準備計畫；(2)強化出院後支持；(3)強化出院後轉介的銜接，以做為出院後追蹤照護及成效評值。本文所規劃之高齡失智長者參與出院準備計畫能有效降低其內在障礙問題（就醫率及住院率上升、家屬和高齡長者本身無力或不知如何照顧、家庭關係失和）與外在障礙問題（提供就醫資訊不充足、應給予家屬心理支持），適合整合於現有出院準備服務中，並對高齡失智長者有具體行動力的成效，經與高齡失智長者建立良好的關係，透過衛教技巧以及會談技巧關懷並追蹤其發展，三個計畫執行對於反應性、專注度、參與度、互動性、情緒性等五項表現有所提升。

Based on practical application, this study assists senior adults to successfully be transferred to other care environments after medical treatment in order to ensure that they receive continuous and positive health care service after discharge from hospital. Thus, their families' caregiver burden can be reduced. Regarding the construction of senior adults' discharge planning, based on the principles and service content of literature, this study develops the primary process for tracking care and outcome evaluation after discharge as follows: 1) improve discharge planning; 2) reinforce discharge support; and 3) reinforce post-discharge transfer. Senior adults' discharge planning constructed by this study can effectively lower their internal obstacles (low compliance rate and high hospitalization rate, helpless families and senior adults, or lack of knowledge of care and negative family relationships) and external obstacles (lack of medical information and psychological support for the families). The constructed process can be integrated into the current discharge service and is effective for improving senior adults' mobility.