Bridging the Gap: Psychosocial Outcomes and Health Behaviors in Patient Discharge Liaison Services in Four Public Hospitals in South Korea

Background and Purpose: The socioeconomic burden caused by chronic diseases is a critical issue worldwide. Since 2019, patient discharge liaison services have been implemented in public hospitals in South Korea to support patients with chronic illness transitioning to community-based care. This service connects patients with community resources after discharge through an interdisciplinary team of physicians, nurses, and social workers, offering medical care, information on resources, and psychosocial support. Although qualitative evidence suggests service recipients experienced overall positive changes, psychosocial outcomes have not been confirmed quantitatively. This study examined the psychosocial outcomes and health behaviors of patients who received these liaison services in South Korea.

Methods: In 2023, 93 patients were recruited from four public hospitals in South Korea; 34 participants dropped out, resulting in a final sample of 59. Participants were 36 men and 23 women ranging from 37 to 96 years old. Participants had been diagnosed with cerebrovascular disease (37.3%), musculoskeletal disease (27.1%), respiratory disease (23.7%), and other chronic diseases (11.9%). Participants enrolled in liaison services received an information session and psychological counseling at admission, followed by an in-person or phone visit within 1 month of discharge. The General Health Questionnaire-12, Multidimensional Scale of Perceived Social Support, Attitudes Towards Seeking Professional Help Scale, European Health Literacy Survey Questionnaire, Physical Health Behavior Scale, and a researcher-developed assessment were used to assess depressive symptoms, social support, help-seeking behaviors, health literacy, health-promoting behaviors, and accessibility of resources before receiving the service and 1 and 3 months after discharge. Linear mixed modeling with a random intercept was used, controlling for sex, age, residential area, caregiver presence, and socioeconomic status.

Results: Accessibility of community resources and help-seeking behaviors significantly improved from baseline to 1 month (B = 0.749, p < .001, d = .601; B = 0.322, p = .044, d = .235, respectively), and this change remained at 3 months (B = 0.814, p < .001, d = .598; B = 0.322, p = .044, d = .239). Social support, health literacy, and health-promoting behaviors had not changed significantly at 1 month, but they significantly improved from baseline to 3 months (B = 0.377, p = .039, d = .246; B = 0.452, p < .001, d = .438; B = 0.339, p = .002, d = .377). Depressive symptoms did not statistically significantly change.

Conclusions and Implications: This study confirmed the positive outcomes of liaison services among discharged patients. This highlights their potential to encourage individuals to access resources and support, alongside the need for more structured and continuous support to enhance self-care. Researchers should explore long-term outcomes and barriers that interfere with community transition among patients with chronic illness. Interdisciplinary teams in hospitals should collaborate with community-based social work agencies to provide accessible services to discharged patients. Such collaboration could enhance patients’ self-management and health-promoting behaviors, thereby strengthening the care system and ensuring continuity of care. Furthermore, social workers in hospital settings should develop tailored interventions based on their patients’ psychosocial needs, using interdisciplinary assessments from initial hospitalization through community transition.