At a time when home care is promoted in Japan, an increasing number of patients requiring high dependency medical care transfer from hospital to home care at an early stage. Nurses and other medical staff need to assess patients’ needs from a professional point of view and respond to their needs in an appropriate and preventive manner. Meanwhile, patients’ needs have become diverse and complex and patients themselves are often uncertain of their future. An assessment could thus be challenging even though predicting the situation following the transition to home care is important. I will discuss the tasks and challenges in patient needs assessment during the care transition.