疾病急性期過後出院準備服務團隊即會進行評估病人後續照顧需求，神經功能障礙病人身體功能因損傷而無法自我照顧，日常生活需依賴他人協助有長期照顧之需求，病人後續照顧問題對於家庭和社會造成相當大的負擔。實務上，醫院的出院準備服務團隊以任務為導向來關注照顧者的需求，其中有相當多值得探討的議題。本研究目的為：(1)藉由出院準備服務團隊之介入，瞭解家屬協助病人社會資源取得之過程；(2)分析家屬對於照顧過程的心路歷程與改變；(3)呈現家屬對醫務社會工作者的感受與期許。本研究採用質性研究方法，透過參與觀察及深度訪談來蒐集資料。研究對象採取立意取樣的方式，選取10位研究對象。本研究結果發現：(1)由於出院準備服務團隊的介入，使家屬協助病人取得資源之過程免於奔波；(2)醫務社會工作者幫助家屬協助病人適時取得資源，解決其照顧問題，使家屬能以正向積極的態度面對，也為家屬尋找可利用的社會福利資源，使家屬經濟層面負擔減少，以提高家屬與病人的生活品質；(3)醫務社會工作者是家庭溝通協調者，其協助家屬與醫療專業團隊溝通，給予家屬心靈及物質上的協助，提供家屬居家及機構照顧資源訊息，並協助家屬轉介其需求之照顧機構。根據研究結果，本研究建議：(1)採用以病人為中心的服務模式：提供全人照顧服務，而非僅以工作導向來服務，意即透過充分整合醫院內資源並連結社區中、家庭及非正式資源一同來照顧病人；(2)主動出擊以利營造角色優勢：主動安排課程在新進醫護人員訓練中，宣導出院準備服務醫務社會工作者之任務，由醫護人員協助轉介至病房提供服務；(3)由醫院來宣導醫務社會工作者之服務內涵：運用多種宣導工具，宣導出院準備服務醫務社會工作者之服務內涵，讓有需要的病人及家庭了解並應用。

After the acute phase of the disease, the Discharge Service Team assesses the patient's needs for follow-up care. The patient is unable to self-care due to physical impairment and relies on others to assist with long-term care. The Discharge Service Team is task-oriented. Need to focus on the needs of caregivers, Also, subsequent care may cause a great burden for the family and society. The purpose of this research is to study patients with neurological disorders who cannot take care themselves, through (1) discharge preparing team involved, (2) social resources available or families (3) the situation of medical social workers and the subsequent care of patients placement. At the same time, analysis (1) the thought and the process changes of taking care of patients, (2) feelings and expectations to those medical social workers, (3) the importance of long-term care in the health system, and further recommendations for its services and policies. This study used qualitative research methods, subject to purposive sampling and selected 10 subjects to collect valid data by reading literature, participant observation and in-depth interviews to collect. The result: (1) discharge preparing team involved: to help families to get available resources without traipsing (2) social resources available or families: solve patient-care problem. Help families to gain positive attitude, looking for available social welfare resources and reduce the economic burden. Eventually, improve the quality of life of patients and their families (3) medical social workers are the coordinator of family communication. To be a bridge of families and professional medical team, giving assistance not only on spiritual, but also physical. Provide information and resources of medical organization to families and help them transfer to another suitable nursing home if needed. Follow-up resource distribution status after the patient is discharged, and the continued use of long-term care services. Giving recommendations according to the research findings, (1) a patient-centered service model: providing a total care service rather than task-oriented to serve patients. Pull together hospital resource in connection to communities, families and informal resources to take care for the sick; (2) Take the initiative to play to create a role in the advantages: take the initiative to the new medical staff training in the discharge of the preparation services to the medical social workers of the task, by the medical staff to assist in referral to the ward to provide services; (3) hospital advocates the intension of medical social workers: make patients to understand the conditions and intension of using long-term care welfare resource via variety of promotional tools.