This study elucidates the situation of patients who need assistance, but have not been transferred to convalescent rehabilitation wards. The researchers conducted interviews with six experienced social workers engaged in transfer assistance about their efforts to protect their patients’ right to receive rehabilitation assistance. The authors used the focus group interview method and the following four important categories were extracted: the suitability of the rehabilitation, the criteria for determining the transfer, groups of patients who are in need but not eligible to be transferred, and the assistance provided by the social worker. Analysis reveals that the social workers, with discretion, tact, and an ecological view of the situation, performed various activities tailored to their patients’ and the environment in which they live including their families and social resources. The authors suggest that a more versatile framework than the current medical policies needs to be established to efficiently help all patients in need of rehabilitation at convalescent wards.