Business Overview
Program Details
Integrated Service Management System
Health management professionals (care managers) conduct comprehensive consultations and assessments of integrated service recipients, considering their physical, psychological, and social environments. Based on a personalized care plan that reflects the recipient’s characteristics and health condition, they provide tailored services (e.g., home-based care, medical and welfare services, and community support), and subsequently conduct performance evaluations.
Download Health Guidebook for the Veterans Medical and Welfare Integrated Service PDF
Integrated Service Coordination and Implementation Framework
고객
- Home-Based Services
- Direct provision of services utilizing the Korea Veterans Health Service’s resources
- Home nursing, home-based rehabilitation, home hospice care, and telephone medical consultations
- Medical and Welfare Services
- Services linked with external resources not held by the Korea Veterans Health Service
- Support from the Ministry of Patriots and Veterans Affairs staff, affiliated hospitals, community resources, and medical expense assistance
- Community-Based Services
- Connection, consultation, and referral services utilizing the Korea Veterans Health Service’s resources (e.g., hospitals, nursing homes)
- Outpatient care, inpatient care, and medication management
Types of Integrated Services
Category |
Service |
Key Details |
|
|---|---|---|---|
VHS Hospital Integrated Services |
|||
Post-discharge care |
Home-based rehabilitation therapy |
Home-based physical therapy, home-based cognitive and occupational therapy |
|
Home nursing services |
Medication management, injections, nursing procedures, and health consulting |
||
End-of-life care |
Home hospice care |
Pain and symptom management, and bereavement counseling |
|
Community resource linkage |
Daily living support |
Consultation and linkage with community resources |
Consultation and care plan development by medical social workers, with linkage to community medical and welfare resources(including support from Ministry of Patriots and Veterans Affairs staff, household assistance, long-term care, and assistance with disability rating applications) |
Home-Based Services
Home Nursing Services
Selection of Service Recipients
STEP 01
- Consultation and assessment of patients referred by the attending physician
- Selection and registration of recipients who meet eligibility criteria
Home Visit
STEP 02
- Visit by a home nurse
- Administration of medication, injections, and nursing procedures according to each patient’s condition
Provision of Service
STEP 03
- Home nursing care: Administration of medication and injections, wound care, simple tests, etc.
- Health counseling and education for patients and caregivers: Exercise guidance, dietary education, etc.
- Medical information and linkage to community resources as needed: Connection to health and welfare services
Patient Monitoring
STEP 04
- Record each patient visit in the Home Nursing Registration Log
- Ongoing patient management via telephone consultations
- Regular monitoring of patient condition during home visits
Home-Based Rehabilitation Services
Selection of Service Recipients
STEP 01
- Identify patients interested in home-based rehabilitation (through the Rehabilitation Medicine outpatient clinic)
- After assessment by the Rehabilitation Medicine attending physician, register patients on the home-based rehabilitation waiting list
Prioritize the selection of patients by district
Home Visit
STEP 02
- Physical therapist home visit: Schedule visits via telephone
- Rehabilitation assessment and therapy using physical and electrotherapy equipment
Provision of Service
STEP 03
- Physical therapy, exercise therapy, and guidance on activities of daily living (ADL)
- Rehabilitation education for patients and caregivers: Instructions on home exercise techniques and patient care methods
- Medical information and linkage to community resources as needed: Connection to health and welfare services
Patient Monitoring
STEP 04
- Regular monitoring of patient condition during home-based rehabilitation sessions
- Ongoing patient management through documentation of rehabilitation assessment records
Home Hospice Service
Selection of Service Recipients
STEP 01
- Referral by the attending physician and identification of patients interested in home hospice care
- Provision of home hospice information and counseling
- Obtaining consent from the patient and caregiver
- Registration of the patient and development of a service plan
Home Visit
STEP 02
- Home hospice team (nurses, social workers, etc.) visits and development of a nursing care plan
- Observation and documentation of the patient’s condition
Provision of Service
STEP 03
- Administration of medication and injections according to each patient’s condition
- Treatment and management of pressure ulcers, wounds, and surgical sites
- Patient counseling and education regarding their illness
Patient Monitoring
STEP 04
- Record each patient visit in the Home Hospice Nursing Registration Log
Ongoing patient management via telephone consultations.
Regular monitoring of patient condition during home visits.
Consult the attending physician if any abnormalities are observed.
- Record each patient visit in the Home Hospice Nursing Registration Log
Home Delivery of Assistive Devices
Selection of Service Recipients
STEP 01
- Selection of recipients for acquisition, trial, fitting, and repair of assistive devices
Home Visit
STEP 02
- Prosthetist/orthotist home visit to provide services
Provision of Service
STEP 03
- Acquisition, trial fitting, and final fitting of assistive devices
- Guidance on proper use of assistive devices and training in rehabilitation methods
- Identify and actively resolve any issues or malfunctions arising from device use
Patient Monitoring
STEP 04
- Conduct a service satisfaction survey one week after service delivery
- If the recipient is dissatisfied, provide the service again
