For elderly persons who started home medical care, prescriptions were reviewed from the viewpoint of proper use, and support was provided through interprofessional collaboration. The patient was a 79-year-old woman with gait disturbance, bath refusal, depression, sleep disorder, and behavioral and psychological symptoms of dementia (BPSD), but conversation increased as the eating habits improved and mental state stabilized, making gait possible. Family support was also a key for amelioration. Intervention resulted in improved quality of life (QOL) and outpatient treatment became possible following home medical care. In order switch from home medical care to outpatient care, it is also important for each person (e.g., pharmacists, nurses, caregivers, nursing care support counselors) to participate as a member of a medical team to quickly sense changes and share information among with the key persons in medical care/nursing care in community-based integrated care system, or the primary care physician.
