Recognized by a U.S. health organization for its excellence, selected as Asia’s first hospital specializing in care for older patients

The multidisciplinary integrated care program ‘WithONE’ strengthens continuity of treatment and connects patients to welfare services

“Aims to advance Korea’s elderly care standards and develop a standardized, patient-centered care system for older patients”

▲ Asan Medical Center is operating the WithONE integrated care system for older patients with severe illnesses. Professor Ji Yeon Baek of the Division of Geriatrics at Asan Medical Center (third from left) and the medical staff conduct a Clinical Frailty Scale (CFS) assessment to identify high-risk patients, measuring the muscle strength of an older patient with a severe condition.

An 85-year-old patient, Mr. A, was admitted to Asan Medical Center for surgery to treat bile duct cancer. During the initial screening process for older patients, he was identified as needing intensive management. Through the hospital’s electronic system, a consult request was automatically sent to the Acute Care for Elders(ACE) Team, and a dedicated geriatric nurse visited the ward to assess his condition.

Following surgery, Mr. A was considered at high risk for postoperative complications, delirium, falls, and malnutrition. Physicians from multiple departments, a pharmacist, and a medical social worker jointly reviewed his condition from various perspectives and provided tailored, intensive care that included early rehabilitation, medication adjustments, nutritional support, and delirium prevention nursing. Before discharge, taking into account his “older caregiver for an older patient” situation, the team developed an integrated discharge plan that linked him to local community welfare services based on his place of residence. After leaving the hospital, a home care nurse continued to visit, providing treatments and education tailored to his living environment, and ensuring a safe and stable recovery.

By establishing a systematic medical care system centered on older patients with severe illnesses, Asan Medical Center has been awarded the highest Care Excellent certification from the Institute for Healthcare Improvement in the United States, becoming the first and only hospital in Asia to be recognized as a specialized hospital for older patients.

The WithONE integrated care program for older patients with severe illnesses, embodies the idea of experts from multiple disciplines working “With” each individual patient “One” to deliver personalized care. The program offers comprehensive services that include ▲ early identification of high-risk patients aged 65 or older at the time of admission ▲ tailored treatment based on a multidisciplinary team approach during hospitalization ▲ and post-discharge connection to community resources.

When a patient aged 65 or older is admitted, their health status is assessed using the Clinical Frailty Scale (CFS). If classified as high-risk, a consult request is automatically sent through the Asan Medical Center’s electronic system to the Acute Care for Elders(ACE) Team.

Taking this a step further, Asan Medical Center also uses its own ‘Care Risk Scale’ to conduct a more detailed assessment and establish personalized treatment plans. The ‘Care Risk Scale’ is designed to help medical staff comprehensively evaluate a patient’s complex health conditions and illnesses, while also predicting prognosis and the likelihood of deterioration.

Within 48 hours of the consult request, a dedicated geriatric nurse visits the patient to assess risk factors and potential causes of deterioration. Personalized care services are then provided through a multidisciplinary program involving collaboration among specialists from various fields.

During this process, the WithONE team at Asan Medical Center incorporates the 4M framework into patient management. Based on four key areas, ‘Matter’ (what matters most to the patient), ‘Mobility’, ‘Medication’, and ‘Mentation’, the team conducts a comprehensive assessment of the patient’s care needs and potential risk factors.

Once an optimal care plan tailored to the needs of older patients with severe illnesses is established, customized medical and supportive services are provided to maximize treatment outcomes. The Rehabilitation Medicine Team at Asan Medical Center offers early rehabilitation therapy to reduce declines in mobility and the risk of falls. The Pharmacy at Asan Medical Center evaluates polypharmacy and the prescription of potentially inappropriate medications for older adults, recommending suitable alternatives to the attending department and providing necessary education to caregivers. The Nutrition and Food Services at Asan Medical Center develops and manages dietary plans for patients at risk of nutritional imbalance.

The WithONE program is designed with a focus on the patient’s life beyond the hospital. To strengthen continuity of care after discharge, the Asan Medical Center operates a community-based ‘Integrated Discharge Planning Service’ that seamlessly connects medical and welfare services. This service helps high-risk patients, such as those living alone, facing care gaps, or experiencing mobility limitations, safely return to daily life while continuing to receive the treatment and support they need.

Based on a thorough understanding of the patient’s condition and treatment process, dedicated nurses and medical social workers consult with the patient’s family to assess care needs and develop a discharge plan. They connect patients with home nursing providers suited to their place of residence and arrange care services linked to local welfare resources. After discharge, the hospital operates a Patient Inquiry Center and a Safe Care Clinic to ensure that patients can quickly receive treatment in case of unexpected situations, and is also developing an AI-based inquiry response system.

The number of older patients managed by the Acute Care for Elders(ACE) Team at Asan Medical Center has grown more than 18-fold, from approximately 160 in 2021 to 2,959 in 2024, with patient satisfaction levels exceeding 90 percent.

During the same period, the number of referrals for the ‘Integrated Discharge Planning Service’ increased nearly tenfold, from 83 to 802 cases, while the number of connections made to community welfare services rose significantly from 191 to 1,449 cases.

▲ Asan Medical Center is operating the WithONE integrated care system for older patients with severe illnesses. Professor Ji Yeon Baek of the Division of Geriatrics at Asan Medical Center (second from right), along with a pharmacist, nutritionist, social worker, and other medical staff, holds a multidisciplinary meeting to establish a personalized care plan for an older patient with a severe condition.

Professor Ji Yeon Baek of the Division of Geriatrics at Asan Medical Center said, “About 40 percent of our inpatients are aged 65 or older, and the proportion of older patients with severe illnesses is relatively high. The key to preventing complications and achieving optimal treatment outcomes for older patients is a rapid and specialized initial response. Through the WithONE program, we will continue to raise the standard of elderly care in Korea and further advance a standardized, patient-centered care system for older patients.”

Professor Ki Young Son of the Department of Family Medicine at Asan Medical Center added, “I believe it is the responsibility of medical institutions to support older patients in living independently after discharge. We will continue to identify diverse community resources and provide tailored welfare services to help improve overall quality of life for patients after they leave the hospital.”

Meanwhile, in 2020 Asan Medical Center launched the Acute Care for Elders(ACE) Committee, comprising the Division of Geriatrics, the Department of Rehabilitation Medicine, the Nursing Department, the Pharmacy, and the Social Service Team. In 2023, it became the first hospital in Korea to evolve this into the Acute Care for Elders(ACE) Team, which identifies high-risk older patients early and provides tailored treatment. In 2024, the team was expanded and reorganized into the Integrated Patient Care and Discharge Planning Team to help establish a senior-friendly care system firmly within the hospital. In 2025, the hospital established the Integrated Discharge Planning Team to further specialize its existing discharge planning service.

Recently, the Asan Medical Center filed a trademark application for WithONE, officially recognizing it as a dedicated care model for older patients with severe illnesses.