On August 4, Seoul Asan Medical Center announced that it has launched its first integrated care system tailored for elderly patients, providing comprehensive support from admission to post-discharge care.
The number of elderly patients with severe conditions visiting advanced general hospitals in South Korea is rapidly increasing. However, integrated care systems that take into account the unique characteristics of elderly patients remain insufficient.
Professor Baek Jiyeon, Department of Geriatrics, Asan Medical Center Seoul (third from the left), and medical staff are conducting the Clinical Frailty Scale (CFS) test to screen high-risk patients and measuring the muscle strength of severely ill elderly patients. Photo by Asan Medical Center Seoul
By establishing a systematic medical system centered on elderly patients with severe conditions, Seoul Asan Medical Center has been awarded the highest Care Excellent certification by the Institute for Healthcare Improvement in the United States. It has become the first and only hospital in Asia to be recognized as a specialized institution for elderly patients.
The integrated care program for elderly patients, WithONE, signifies that experts from various fields work together (With) to provide personalized care for each individual patient (ONE). The program includes: early identification of high-risk groups among patients aged 65 or older at the time of admission; multidisciplinary, team-based personalized care during hospitalization; and integrated services that extend to community connections after discharge.
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, the hospital’s electronic system automatically refers the patient to the Senior Patient Management Team for collaborative care.
Seoul Asan Medical Center goes a step further by using its self-developed "Care Risk Scale" to conduct a more precise diagnosis and establish a tailored treatment plan. The Care Risk Scale is designed to allow medical professionals to comprehensively evaluate the patient’s complex health conditions and diseases, as well as to predict prognosis and the likelihood of deterioration.
Within 48 hours of the referral, a dedicated geriatric nurse visits the patient to assess risk factors and potential for future deterioration. A multidisciplinary team of specialists then collaborates to provide customized care services through the program.
Specialized Management for Elderly Patients: Care and Mobility
During this process, the WithONE team at Seoul Asan Medical Center manages patients through the 4M service. The team conducts a comprehensive assessment of the patient’s care needs and potential risk factors based on four domains: Matter (care needs), Mobility (physical movement ability), Medication (medication management), and Mentation (mental function).
Once an optimal care plan tailored for elderly patients with severe conditions is established, personalized medical and care support is provided to maximize treatment outcomes. The rehabilitation medicine team offers early rehabilitation therapy to reduce the decline in mobility and the risk of falls. The pharmacy team evaluates polypharmacy and potential inappropriate medication prescriptions for elderly patients, recommends suitable medications to the attending department, and provides necessary education to caregivers. The nutrition team develops and manages dietary plans for patients at risk of nutritional imbalance.
The WithONE program is designed to take into account patients’ lives after they leave the hospital. To strengthen continuity of care after discharge, a community-based "Integrated Discharge Planning Service" is operated, seamlessly connecting medical and welfare services. This helps high-risk patients?such as those living alone, those with care gaps, or those with mobility limitations?safely return to daily life and continue receiving necessary treatment or care.
Professor Jiyeon Baek, Department of Geriatrics, Asan Medical Center, Seoul (second from the right), along with pharmacists, nutritionists, and social workers, is establishing a customized treatment plan for severely ill elderly patients through a multidisciplinary meeting. Photo by Asan Medical Center, Seoul
Dedicated nurses and social workers consult with patients’ families about discharge plans based on an understanding of the patient’s condition and treatment process, identifying care needs. They connect patients with home nursing agencies tailored to their place of residence and provide care services linked to local welfare resources. A post-discharge inquiry center and Safe Care Clinic are operated to ensure patients can quickly receive medical attention in emergencies, and an AI inquiry response system is currently under development.
Number of Elderly Patients Increased 17-Fold in 3 Years... Satisfaction Rate Exceeds 90%
The number of elderly patients managed by the Senior Patient Management Team at Seoul Asan Medical Center increased from about 160 in 2021 to 2,959 in 2024, an increase of more than 18 times. The program’s satisfaction rate exceeded 90%.
During the same period, the number of referrals to the Integrated Discharge Planning Service rose from 83 to 802, about a tenfold increase, and the number of connections to community welfare services also grew significantly from 191 to 1,449.
Baek Jiyeon, a professor of geriatric medicine at Seoul Asan Medical Center, said, "About 40% of inpatients at Seoul Asan Medical Center are aged 65 or older, and the proportion of elderly patients with severe conditions is high. The key to preventing complications and achieving optimal treatment outcomes for elderly patients is a prompt and professional initial response. Through the WithONE program, we will enhance the level of elderly care management in Korea and further develop a standardized, patient-centered care system tailored for elderly patients."
Son Kiyoung, a professor of family medicine at Seoul Asan Medical Center, stated, "I believe that supporting elderly patients to live independently after discharge is also the role of medical institutions. We will continue to discover various local resources and provide personalized welfare services to ensure the overall quality of life after discharge is improved."
Meanwhile, in 2020, Seoul Asan Medical Center launched the Senior Patient Committee, composed of the Department of Geriatric Medicine, Department of Rehabilitation Medicine, Nursing Department, Pharmacy Team, and Social Work Team. In 2023, it developed into the Senior Patient Management Team, the first in Korea to provide early identification and personalized treatment for high-risk elderly patients. In 2024, it was expanded and reorganized into the Integrated Care Support Team to ensure the elderly-friendly care system was firmly established within the hospital. In 2025, the Integrated Discharge Planning Team was established to further professionalize the previously operated integrated discharge service.
Recently, the name WithONE has been filed as a trademark, formalizing it as a dedicated medical model for elderly patients with severe conditions.
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