一位個案管理師正在查閱內外科病房中四名病患的檔案。下列哪一位病患呈現了需要立即召開跨科別團隊會議，以安排複雜出院後銜接服務的最高優先級？
A case manager is reviewing the files of four clients on a medical-surgical unit. Which client presents the highest priority for an immediate interdisciplinary care conference to arrange complex post-discharge transition services?
- AA 30-year-old female successfully treated for pyelonephritis with 3 days of IV antibiotics eagerly waiting to return to her desk job.一名 30 歲女性，經 3 天靜脈注射抗生素成功治療腎盂腎炎，正急切等待返回辦公室工作。
- BA 45-year-old homeless male admitted for a severe asthma exacerbation now stable on oral corticosteroids and an albuterol inhaler.一名 45 歲無家可歸男性，因嚴重氣喘急性發作入院，目前口服皮質類固醇及使用 albuterol 吸入器後狀況穩定。
- CA 55-year-old female post-uncomplicated laparoscopic cholecystectomy returning home to her spouse and teenage children.一名 55 歲女性，接受未併發症之腹腔鏡膽囊切除術後，將返家與配偶及青少年子女同住。
- DA 72-year-old male recently diagnosed with advanced ALS (Amyotrophic Lateral Sclerosis) who lives alone constantly falling and struggling to chew solid foods.✓ 正解一名 72 歲男性，近期確診為晚期肌萎縮性脊髓側索硬化症（ALS），獨居，不斷跌倒且難以咀嚼固體食物。
本題測驗出院計畫與個案管理 (Case Management / Continuity of Care)。個案管理師 (Case Manager) 的核心職責在於整合那些出院後「照護需求極為複雜、缺乏社會支持系統或極度容易反覆入院」的高風險病患。選項 D 的 72 歲男性具備了所有高風險指標：他罹患了無法治癒且不斷惡化的肌萎縮性脊髓側索硬化症 (ALS，漸凍症)，他獨居缺乏家庭支持，且出現了跌倒（行動能力瓦解）與吞嚥困難（隨時有吸入性肺炎危險）。他出院時必然需要大量極其複雜的居家照護銜接，包括語言/吞嚥治療師、物理治療師、居家照服員甚至是長照機構的安置安置。因此他絕對是需要跨科團隊 (Interdisciplinary team) 介入的最優先對象。選項 B 雖然是無家可歸的弱勢族群，但他的氣喘目前穩定且僅需藥物衛教，其醫療複雜度不及漸凍症獨居長者。選項 C 膽囊切除術後健康且有家人支持，是最順利的出院型態。選項 A 腎盂腎炎已治癒隨時可復工。
The 72-year-old client with advanced ALS living alone presents the highest priority for discharge planning due to multiple high-risk factors, including a progressive neurodegenerative disease, lack of social support, and complications like frequent falls and dysphagia. These issues require complex interdisciplinary coordination for home care, therapy services, and potential long-term placement to ensure safe transition and prevent readmission.
Case Management (個案管理) 在台美都非常關注「出院準備服務」。獨居老人＋不可逆之退化性疾病疾病 (ALS/Dementia)＋跌倒史，是永遠的 VIP 頭號評估對象。