퇴원환자 지역사회 연계사업 개선을 위한 질적연구:방문건강관리사업과의 연계를 중심으로*

Abstract

= Abstract = Objectives: Effective coordination between medical and community-based services is essential to support discharged patients’ recovery and reintegration into daily life. This study aimed to explore operational challenges and institutional constraints in the Community Linkage Program for Discharged Patients(CLDP) and to identify strategies for strengthening the program, with a focus on integration with home visiting health services. Methods: In-depth interviews were conducted with 22 practitioners from designated public hospitals (Accountable Care Hospitals) and public health centers, including one branch, in Gyeongsangnam-do. Thematic analysis was applied to identify key themes related to program implementation and service integration. Results: Major obstacles to effective operation and sustainability included fragmented information systems, inconsistent referral procedures, limited integration with home visiting health services, and instability in the frontline workforce. Practitioners suggested strategies such as standardizing referral protocols, upgrading the Public Health Connected platform, improving caregiver information support, and establishing regionally coordinated care networks. Conclusions: This qualitative study revealed critical implementation issues and practical strategies to improve the effectiveness of the post-discharge Community Linkage Program. Strengthening system integration, standardizing inter-agency procedures, enhancing collaboration with home visiting services, and ensuring workforce stability are essential. These findings provide actionable insights for policy development to support a sustainable, community-based care system for discharged patients.