RESUMO
Since 1993, our hospital has been entrusted by the Gifu Prefectural Government with the operation of the home health care system in the region. Hospital healthnurses, keeping in close contact with other medical institutions and self-goverinig bodies, have endeavored to support the health and medical care of home patients.<BR>Initially, there was much to be desired in the way some government offices were addressing to home health care and care coordination for patients when they were discharged from hospital. These inadequacies have largely been corrected and in 1998 a comprehensive home care system came into being.<BR>Our effort to restructure the home care system has been crowned with success in many ways. Formerly there were many cases in which individual organizations rendered services separately, but now hospitals, local medical associations and government offices have come to play on the team, which has made it possible to provide home care effectively and efficiently. Moreover, the hospital staff have become fully aware of the importance of home care.