Seoul Asan Hospital Launches Senior Patient Management Team: "Customized Care from Admission to Discharge"

Seoul Asan Medical Center announced on the 16th that it has officially started operating the Senior Patient Management Team, which provides specialized care for elderly patients from admission to post-discharge.

The Senior Patient Management Team selects high-risk frail patients who require intensive support in advance by evaluating elderly patients admitted to the hospital using the Clinical Frailty Scale (CFS). The Clinical Frailty Scale is a method that quickly observes the patient’s mobility and ability to perform daily activities to measure the degree of frailty.

Additionally, the team introduced the '4M' concept, which categorizes the complex issues elderly patients may face during treatment into ▲What Matters (patient’s needs) ▲Medication ▲Mentation (mental health) ▲Mobility. Based on the 4M framework, the Senior Patient Management Team, led by geriatric specialists and nurses, collaborates with the nursing department, pharmacy team, social welfare team, and rehabilitation medicine team to identify patients’ needs and potential risk factors and establish treatment plans tailored to the characteristics of elderly patients.

To build a treatment system specialized for elderly patients, Seoul Asan Medical Center has been operating the Senior Patient Committee since 2020, which consists of experts from various fields including geriatrics, the Senior Health Center, allergy medicine, emergency medicine, rehabilitation medicine, family medicine, nursing, pharmacy, and social welfare. The center also introduced a dedicated geriatric nurse system to closely monitor the overall condition of high-risk elderly patients and provide education and counseling for elderly patients and their caregivers.

An Integrated Discharge Planning Center is also being established to provide medical services even after discharge. Through this, customized discharge plans tailored to each situation will be developed for high-risk elderly patients, linked to community medical and welfare services, and a dedicated communication channel after discharge will be set up to ensure a safe discharge process.

Jang Il-young, head of the Senior Patient Management Team and professor of geriatrics at Seoul Asan Medical Center, said, “Just as pediatric patients differ from adult patients, elderly patients have distinct characteristics. The specialized treatment system for elderly patients at Seoul Asan Medical Center is currently implemented in some departments with a high proportion of severe elderly patients, but as our society ages rapidly, we plan to expand its application.”

He added, “We will gather experts from various fields to find the best solutions in many ways so that elderly patients admitted to the hospital can receive treatment with peace of mind and return to their daily lives as healthily and quickly as possible after discharge.”