In a case of patient who transfers from hospital-stay to homecare, a pre-discharge conference will be held on behalf of the patient, family and regional staff along with our hospital support guideline system. We would make sure at the conference whether a continued care provided to the patient will seamlessly be offered before and after the discharge. The transfer care arrangement was normally taken place while a patient was still at the hospital. We analyzed the interview evaluation done by the patient, family, and regional staff: three cases with a successfully transferred to the regional home were chosen because they attended the pre-discharge conference more than twice while they were at hospital. All cases had received an arranged care continuously. It seems that the arranged caring was appropriate for the patient and family.