Director Eunju Lee of the Senior Patient Committee and Team Leader Ki Young Son of the Integrated Discharge Planning Team  (third and fourth from right), discuss the future development of the integrated discharge planning service with medical staff.

An 83 year old man, referred to as Patient A, was admitted to Asan Medical Center after being diagnosed with lung cancer that had spread to other parts of his body, causing severe pain. Repeated rounds of chemotherapy had also significantly reduced his appetite, to the point where he could barely tolerate the smell of food. As he lived alone in Yeosu, South Jeolla Province, and had cognitive decline and limited mobility, there were concerns about a potential gap in care after discharge.

After being enrolled in WithONE, Asan Medical Center’s integrated care system for older patients with severe illnesses, Patient A was connected with early rehabilitation, nutritional counseling, medication management, and an integrated discharge planning service. Beginning the day after the referral, his walking ability was assessed and bedside rehabilitation therapy was initiated. A clinical dietitian from the Nutrition and Food Services provided a high-calorie, high-protein diet tailored to his condition. By the time of discharge, his mobility had improved compared with when he was admitted, and his food intake had increased by more than 30 percent.

Before discharge, a social worker from the Integrated Patient Care and Planning Team held an in-depth consultation with Patient A to identify ways to ensure his safety and continued care after returning home to Yeosu. He was provided with information on a range of community based welfare services, including home modifications, meal support, emergency safety services, home care services, transportation assistance for people with limited mobility, and welfare equipment. Information was also provided on home nursing services available through hospitals in the Yeosu area.

After discharge, Patient A has been receiving home nursing care three times a week, allowing him to continue his recovery with systematic and coordinated care at home.

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Asan Medical Center has successfully operated WithONE, an integrated care system for older patients with severe illnesses that brings together the medical and care services they need within a single coordinated system. The program is helping reduce the risk of hospital readmission and gaps in post-discharge care.

Through WithONE, a multidisciplinary integrated care model for older patients, more than 10,000 older patients have received personalized medical and care services over the past five years. Upon admission, patients undergo an assessment of their frailty and are connected with services such as medication management, early rehabilitation and discharge planning counseling tailored to their individual needs.

Older patients with severe illnesses are at risk of developing problems such as falls, delirium and complications during hospitalization. After discharge, many are readmitted as their health deteriorates due to factors including declining physical function, difficulties managing medications and gaps in care. Some also have limited access to information about community care services, which can prevent them from receiving the support they need in a timely manner.

Recognizing these challenges, Asan Medical Center established the Senior Patient Committee in 2020 and has been leading efforts to develop a care system that ensures continuity of treatment for older patients with severe illnesses. In 2021, the system was expanded to provide integrated medical and care services from hospitalization through the post-discharge period. In June 2025, Asan Medical Center filed a trademark application for the system under the name “WithONE.”

The name “WithONE” reflects the system’s goal of providing personalized care to each individual patient (ONE) through collaboration among experts from various fields (With). It is an integrated care system specifically designed for older patients with severe illnesses, encompassing early screening of high-risk patients aged 65 and older at admission, personalized multidisciplinary care during hospitalization, and coordination with community services after discharge.

Over the five years since 2021, a total of 10,741 older patients have used the WithONE integrated care system for older patients with severe illnesses. The number of patients using the service reached 3,951 in 2025, an increase of approximately 33.5 percent from 2,959 in 2024.

During the same period, a total of 5,122 cases of personalized social welfare services were coordinated for older patients after discharge. WithONE is regarded as Korea’s first specialized medical model for older patients with severe illnesses to provide “close care” extending from hospitalization through their recovery in daily life after discharge.

When patients aged 65 and older are admitted, their overall health status is assessed using the Clinical Frailty Scale (CFS) and the Acute Care for Older People (ACOP) risk assessment to identify those at high-risk of deterioration at an early stage.

Within 48 hours of receiving a referral, a nurse specializing in geriatric care visits the patient and conducts a detailed assessment to identify potential risks of deterioration related to geriatric syndromes such as delirium and falls. A multidisciplinary team of healthcare professionals then works together to develop a personalized care plan based on the patient’s overall health status.

The team comprehensively assesses the patient’s care needs and potential risk factors based on the four key areas of the 4Ms framework: What Matters, Mobility, Medication and Mentation.

Since 2025, Asan Medical Center has expanded the scope of high-risk inpatients requiring medication management and strengthened its medication management system. In 2025, WithONE pharmacists reviewed and managed patients’ medications in a total of 3,915 cases.

The early rehabilitation program has also been expanded to include a total of 22 departments, with a fast-track system introduced to facilitate prompt referrals. In 2025, 926 older patients received early rehabilitation through WithONE, with a total of 3,543 treatment sessions provided. In addition, cognitive rehabilitation was newly incorporated into the early rehabilitation program to support the recovery of both physical and cognitive function.

Furthermore, Asan Medical Center serves as a bridge between patients and community resources through its integrated discharge planning service. Before discharge, dedicated nurses and social workers counsel patients to assess their home environment and caregiving needs in advance and connect them with the medical and care services they will need after returning home.

In fact, 84 percent of patients who used the integrated discharge planning service initially reported no particular needs. However, in-depth counseling revealed previously unidentified needs for support in various areas, including housing, meals and finances. This demonstrates how the hospital proactively identifies care needs that patients may not recognize themselves and connects them with appropriate services to help minimize gaps in care.

As the integrated discharge planning service has become more systematic, its outcomes have continued to grow. The number of cases in which personalized social welfare services were coordinated for patients after discharge increased nearly sevenfold over five years, from 191 cases in 2021 to 1,351 cases in 2025.

Asan Medical Center also operates a “Post Discharge Inquiry Center” and a “Reassurance Care Clinic” to provide systematic support for older patients with severe illnesses, helping them recover in their daily lives without anxiety and receive timely medical care when in person consultations are needed. In addition, the hospital provides home nursing services through specialized home care nurses, each with an average of more than 25 years of clinical experience, who visit patients and provide nursing care based on physicians’ orders.

Going forward, Asan Medical Center plans to further develop a community-based continuity of care model in conjunction with community care services under the Integrated Care Act. The hospital will strengthen intensive follow-up for 30 days after discharge and expand collaboration with home-based healthcare providers and community organizations. Asan Medical Center is also developing an AI call bot for post-discharge support, allowing discharged patients to access necessary information and receive assistance whenever they need it.

Director Eunju Lee of the Senior Patient Committee and a professor of the Division of Geriatrics at Asan Medical Center, said, “Our efforts to develop the WithONE system by exploring ways to establish an integrated care system for older patients are now producing meaningful results. We hope WithONE will serve as a useful model for other healthcare institutions in Korea seeking to establish care systems for older patients with severe illnesses, enabling patients to enjoy healthy and stable later years in their communities without interruptions in treatment or care.”

Team Leader Ki Young Son of the Integrated Discharge Planning Team and a professor of the Department of Family Medicine at Asan Medical Center, said, “For an integrated care system to operate effectively, hospitals must continue supporting patients after discharge so they can safely and confidently return to their communities. We will continue to actively incorporate patient feedback and further develop the WithONE system, providing comprehensive support so that older patients with severe illnesses can continue their recovery with confidence after discharge.”