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PAC program—weakness and old age

The National Health Insurance Administration announced the revised PAC program, which has been implemented since July 1, 2017 to expand care for patients with traumatic nerve injury, fragile fracture, heart failure, and weakness and aging, in addition to stroke and burns.

Benefits of case admission

After the acute phase, the potential for rehabilitation is assessed by the medical team and the patient will receive inter-hospital discharge preparation services and functional assessment before referred to the hospital with a "PAC team" near their home. Through the personalized treatment plans developed by the team to meet patients' needs, patients can receive intensive rehabilitation and integrated care within the treatment period

The care contents of the PAC team include: medical treatment, nursing, medication, physical, functional, language rehabilitation, social work, nutrition, case management and health education, comorbidity, prevention and treatment of complications.

Expense burden

With the PAC integration model (long-term care—seamless transition) targeted at frail, elderly patients, all eligible patients can be admitted to PAC wards. Under the Integrated care model, patients are hospitalized for 2 to 3 weeks for rehabilitation based on their symptoms and personal conditions, with 5% of medical fees required under the National Health Insurance scheme.

Conditions for admission

1. Elderly patients≧ 75 years of age
2. Having any of the following diseases in the past:
   1. Parkinson's disease
   2. Chronic obstructive pulmonary disease
   3. Dementia
   4. Stage 3 chronic kidney disease or above
3. Hospitalization for acute diseases (hospitalization time > 72 hours).
4. Functional decline within one month after completion of treatment.
5. Clinical Frailty Scale (CFS) 5-7 points (assessed by case managers).
6. Stable medical condition (no need for intensive medical intervention, testing or oxygen users).
7. With the cognitive and communication skills following treatment, there are opportunities for recovery and physical strength for rehabilitation.

What to do after the completion of the PAC program?

When the patient recovers, the care team will at the end of the program provide consultation telephone services, home care and skill guidance, follow-up rehabilitation treatment advice and referral to community medical resources as needed, such as referral to the family medical plan’s community medical group, home care integration plan team, or social resources services. Based on the assessment results, the team would contact long-term care institutions or provide referral to social welfare institutions.