RESUMO
Due to promotion of home medical care, the number of patients who highly depend on medical care is increasing. Therefore, the role of pre-discharge conferences where a care manager is involved starting from pre-discharge support has become more important. In addition, in a usual relationship, cooperation between the hospital staff and the home care support team is crucial. Among home care workers, the word "coordination" has generally been used for a long time to prepare for the transfer of patients from a hospital to home. However, there is a considerable gap between healthcare and caregiving; consequently, it is difficult to actually create coordination between them because the terms to be used and the contents mastered by personnel in each field are different. In this paper, we report a case of successful coordination for smooth transfer of a patient with ALS from a hospital to home, by creating a homecare team in which all members work together based on the information obtained from a hospital social worker.
