The discharge support system has been constructed in our hospital. This system clarified a flow of regional alliances such as screening, discharge support, and conference with multi-occupational category. We report two cases which received a continued caring by using this system. Patient's information, problems, and mutual goals were shared after the construction of the system. An effective use of conference prior to a hospital discharge made it possible that people in the multi-occupational category could cooperate and use their own skills whenever required to get the job done. This time, we have enhanced cooperation with the staff in the region because we were able to give guidance in collaboration with the patients, their family and care manager.