Thursday 19th September 2019 11:00am-12:15pm Part A: Seamless Discharge Plan: From Acute Care to Community Older people are low reserved and vulnerable to developing a disability from the acute illness during hospitalization. Comprehensive geriatric assessment and multidisciplinary care should be applied for good quality care during hospitalization. Facing the disability, integrated discharge plan and seamless community service are necessary to be provided. In this session, we will introduce the aged-friendly care model and integrated discharge plan for older people. After this session, participants will be able to:

1. Understand that older people are at risk for disability while hospitalization.
2. Remodel the care process of geriatric care during hospitalization.
3. Provide the integrated discharge plan and seamless community service.

Ming-Yueh Chou, Director, Division of Geriatric Integrated Care, Center for Geriatrics and Gerontology, Kaohsiung Veterans General Hospital; Taiwan Part B: Teamwork with "Esther's" best in mind How to plan, act and do the best transition from hospital care to home care. It is regarded as very difficult to plan the transition from hospital care to home care. In Uppsala, Sweden we have created a model for transition that has dramatically improved the care and we like to share our insights. At the same time we will learn from the discussion. We all teach, all learn! After this session, participants will be able to:

1. Understand how to engage the elderly in the improvement process.
2. Engage different providers sharing the same goal.
3. Understand the main obstacles in providing the best care for “Esther”.

Robert Kristiansson, Chief medical officer, Region Uppsala; Sweden