Acknowledgement
이 논문은 2025년도 교육부 및 강원특별자치도의 재원으로 강원 RISE센터의 지원을 받아 수행된 지역혁신중심 대학지원체계(RISE)의 결과입니다(2025-RISE-10-009).
References
- Ministry of the Interior and Safety, Presidential Committee on Ageing Society and Population Policy. South Korea officially enters a super-aged society as of December 2024. Seoul: Ministry of the Interior and Safety; 2024; Dec 23. Available from: https://www.betterfuture.go.kr/front/policySpace/scrapDetail.do?articleId=344
- National Health Insurance Service. 2023 National Health Insurance Statistical Yearbook. Wonju: National Health Insurance Service. 2023. Available from: https://www.hira.or.kr/bbsDummy.do?pgmid=HIRAA020045020000/&brdScnBltNo=4&brdBltNo=2319
- World Health Organization. Integrated care for older people: Guidelines on community-level interventions to manage declines in intrinsic capacity. Geneva: WHO. 2017. Available from: https://www.who.int/publications/i/item/9789241550109
- Australian Government Department of Health. Transition Care Program. Canberra: Australian Government Department of Health. 2025 Oct 1 [cited 2025 Oct 3]. Available from: https://www.health.gov.au/our-work/transition-care-programme
- Brown CL, Tittlemier BJ, Tiwari KK, Loewen H. Interprofessional teams supporting care transitions from hospital to community: A scoping review. International Journal of Integrated Care. 2024;24(2):1. https://doi.org/10.5334/ijic.762
- Morkisch N, Upegui-Arango LD, Cardona MI, van den Heuvel D, Rimmele M, Sieber CC et al. Components of the Transitional Care Model (TCM) to reduce readmission in geriatric patients: A systematic review. BMC Geriatrics. 2020;20(1):345. https://doi.org/10.1186/s12877-020-01747-w
- Kim M, Choi K, Ji H, Park G. Roles and challenges of medical social workers in public hospitals participating in community linkage programs for discharged patients. Critical Social Policy, 2023;81:145-95.
- Tyler N, Hodkinson A, Planner C, Angelakis I, Keyworth C, Hall A et al. Transitional care interventions from hospital to community to reduce health care use and improve patient outcomes: a systematic review and network meta-analysis. JAMA Network Open. 2023;6(11):e2344825. https://doi.org/10.1001/jamanetworkopen.2023.44825
- Collet R, van Grootel J, van der Leeden M, Verbunt J, Geerars M, Bleijenberg N et al. The impact of multidisciplinary transitional care interventions for complex care needs: A systematic review and metaanalysis. Gerontologist. 2025;65(6):gnaf088. https://doi.org/10.1093/geront/gnaf088
- Jin Y, Guo X, Cadilhac DA, He Y, Zhao J, Li X, et al. Clinical staff's perceptions of transitional care from hospital to home for stroke patients: A qualitative study. BMC Nursing. 2025;24:268. https://doi.org/10.1186/s12912-025-02934-z
- Kim HJ, Park JH, Yoo JY. Barriers and facilitators in multidisciplinary discharge planning in long-term care hospitals. The Journal of Korean Gerontological Nursing. 2020;22(3):173-84.
- Park SY, Choi JS, Shin DS. Challenges of discharge support team operation in long-term care hospitals: A mixed-methods study. Korean Journal of Adult Nursing. 2022;34(5):473-85. https://doi.org/10.7475/kjan.2022.34.5.473
- Borich GD. A needs assessment model for conducting follow-up studies. Journal of Teacher Education. 1980;31(3):39-42. https://doi.org/10.1177/002248718003100310
- Mink O, Shultz J, Mink B. Developing and managing open organizations: a model and method for maximizing organizational potential. Austin (TX): Somerset Consulting Group; 1991.
- Rütten A, Gelius P, Abu-Omar K. Policy development and implementation in health promotion—from theory to practice: the ADEPT model. Health Promotion International. 2011;26(3):322-9. https://doi.org/10.1093/heapro/daq080
- Marini G, Longhini J, Ambrosi E, Canzan F, Konradsen H, Kabir ZN. Transitional care interventions improving patient and caregiver outcomes after discharge: A scoping review. Healthcare (Basel). 2025;13(3):312. https://doi.org/10.3390/healthcare13030312
- World Health Organization. Decade of Healthy Ageing 2021-2030: Plan of action. Geneva: WHO; 2020. Available from: https://www.who.int/publications/m/item/decade-of-healthy-ageing-plan-of-action
- Ministry of Government Legislation. Act on integrated support for community care including medical and nursing services (law No. 20415, March 26, 2024). Seoul: Ministry of Government Legislation; 2024. Available from: https://www.law.go.kr/LSW/lsRvsDocListP.do?chrClsCd=010202&lsId=014633&lsRvsGubun=all
- Agency for Healthcare Research and Quality (AHRQ). Strategy 4: care transitions from hospital to Home—IDEAL discharge planning. Rockville, MD: AHRQ; 2024 update. Available from: https://www.ahrq.gov/patient-safety/patients-families/engagingfamilies/strategy4/index.html
- King HB, Battles J, Baker DP, Alonso A, Salas E, Webster J et al. TeamSTEPPSTM: Team strategies and tools to enhance performance and patient safety. In: Henriksen K, Battles JB, Keyes MA, Grady ML, editors. Advances in Patient Safety: New Directions and Alternative Approaches. Vol. 3. Rockville (MD): Agency for Healthcare Research and Quality (US); 2008. Available from: https://www.ncbi.nlm.nih.gov/books/NBK43686/
- Centers for Disease Control and Prevention. Staffing and training for the National Diabetes Prevention Program (National DPP) Lifestyle Change Program. Atlanta (GA): Centers for Disease Control and Prevention; 2024 [cited 2025 Aug 11]. Available from: https://www.cdc.gov/diabetes-prevention/php/program-provider/staffing-and-training.html
- Australian Institute of Health and Welfare (AIHW). Digital health. Canberra: AIHW; 2025 Feb 4. Available from: https://www.aihw.gov.au/reports/australias-health/digital-health
- Australian Government Department of Health and Aged Care. Prepare for the new aged care act—education and training (eLearning). Canberra: DoHAC; 2025. Available from: https://www.health.gov.au/our-work/aged-care-act/prepare
- Tsutsui T. Implementation process and challenges for the community based integrated care system in Japan. International Journal of Integrated Care. 2014;14:e002. https://doi.org/10.5334/ijic.988
- Sano J, Yokobayashi K, Fukuda Y. An overview of systems for providing integrated and long-term care services for older people in Japan. Archives of Public Health. 2023;81:71. https://doi.org/10.1186/s13690-023-01076-5
- The Japan Geriatrics Society. The Japan Geriatrics Society 2025 position statement on community-based integrated care and geriatric practice. Geriatrics and Gerontology International. 2025;25(10):e70228. https://doi.org/10.1111/ggi.70228
- Tamiya N, Noguchi H, Nishi A, et al. Population ageing and wellbeing: lessons from Japan's long-term care policy. Lancet. 2020;395(10231):1183-92. https://doi.org/10.1016/S0140-6736(11)61176-8