背景:隨著老年人口增加、慢性病盛行，提供連續性的醫療照護成為重要議題。若能經由專業人員共同努力，將片段的醫療資源整合，建立完整照顧模式，使病患及家屬獲得連續性、具時效性之照護，將能有效提升照護品質及降低醫療資源成本。目的:介紹出院準備服務及個案管理兩種連續性照護模式，透過系統性文獻回顧方式分析資料，瞭解其連續性照護的內涵與成效。方法:搜尋各資料庫於1999年2月至2010年3月之10年文獻，在Medline、PubMed、Cinahl Plus with full Text、ProQuest、Cochrane Library、CEPS中文電子期刊與CETD中文電子學位論文整合之6個中、英文資料庫，找出以出院準備服務、個案管理為主要介入措施之隨機控制實驗研究。結果:搜尋發現臨床實驗性研究共70篇相關文章，但只有7篇為隨機控制實驗研究。彙整後發現連續性照護有三種服務型態：出院計畫、個案管理、兩者合併；執行內涵為病患入院後或出院前進行評估、訂定計畫、護理指導、團隊間協調、追蹤病患及相關評值之邏輯系統性步驟。介入成效中以探討自我照顧知識、平均住院天數、醫療成本、生活品質等指標呈正向成效。結論與應用:本文檢視出院準備服務與個案管理的對象、介入時間、成員、內容、介入措施、成效指標及結果，將有助於連續性照護的推行，並提供未來研究方向之參考。

Background: Population aging has caused significant rises in the prevalence of chronic diseases and the utilization of healthcare services in Taiwan. The current healthcare delivery system is fragmented. Integrating medical services may increase the quality of healthcare, enhance patient and patient family satisfaction with healthcare services, and better contain healthcare costs.Purpose: This article introduces two continuing care models: discharge planning and case management. Further, the effectiveness and essential components of these two models are analyzed using a systematic review method.Methods: Articles included in this systematic review were all original articles on discharge-planning or case-management interventions published between February 1999 and March 2013 in any of 6 electronic databases (Medline, PubMed, Cinahl Plus with full Text, ProQuest, Cochrane Library, CEPS and Center for Chinese Studies electronic databases).Results: Of the 70 articles retrieved, only 7 were randomized controlled trial studies. Three types of continuity- of-care models were identified: discharge planning, case management, and a hybrid of these two. All three models used logical and systematic processes to conduct assessment, planning, implementation, coordination, follow-up, and evaluation activities. Both the discharge planning model and the case management model were positively associated with improved self-care knowledge, reduced length of stay, decreased medical costs, and better quality of life.Conclusions / Implications for Practice: This study cross-referenced all reviewed articles in terms of target clients, content, intervention schedules, measurements, and outcome indicators. Study results may be referenced in future implementations of continuity-care models and may provide a reference for future research.