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Background: High risk population numbers measured by nursing staff differ greatly from those measured by case managers due to differences in screening approaches used in discharge planning services. Purpose: This project intended to identify and analyze the relevant problems and develop an improvement plan to reduce the discrepency. Methods: The authors observed the clinical situation, interviewed nurses, and designed a questionnaire to evaluate the suitability of a designed screening table to collect nurses' opinions on a high risk population checklist. Based on collected data, we identified and analyzed the cause of the gap, then revised current measurement tools to improve efficacy. Results: Strategies included providing in-service education related to discharge planning for nurses, revising discharge planning manuals, and re-developing the screening scale for high-risk populations. After implementation of the intervention, the difference of screening the high risk population between nursing staff and case manager decreased from 45.9% to 6.7%, and the hit rate on the discharge planning page on the e-learning web site increased to 89.8%. Conclusion / Implications for practice: Results showed that interventions enhanced nurse capabilities in screening high risk populations in the ward, and effectively elevated the accuracy of screening high-risk patients in discharge plans, thus elevating outpatient care quality. This project is suggested as a reference for hospitals developing training programs for discharge planning seed nurses in the wards. Once completed, these nurses can help expand the scope of discharge service to ensure medical resources are used more effectively. [ABSTRACT FROM AUTHOR]