2.5 Aftercare

Follow-up care should include all measures taken by the hospital to actively plan the patient's further care after discharge from inpatient treatment and to gather information about the further course of treatment that may be useful for assessing its own service provision and for reviewing the success of treatment (follow-up examination). All aftercare procedures should be outlined. The hospital must maintain structured contact with the doctors providing further treatment, nursing and social services and with self-help groups.

Post-inpatient care

Post-inpatient care should be planned during the patient's inpatient stay in close cooperation with general practitioners (especially family doctors), nursing services, relatives, rehabilitation facilities and other providers. Corresponding arrangements should be made as part of the treatment process. A further aim of the planning can be to prove that the hospital is not misallocated with patients.

On discharge, the patient should be given appropriate information on the further course of treatment, lifestyle and the use of medication or aids. It should be noted that for most patients, non-medical problems are the main focus on discharge. If possible, a dedicated "social service" should be set up in the hospital to offer patients support and solutions to non-medical issues arising in connection with hospital treatment.

It should also be noted that brochures or leaflets are often not enough information. Many patients and their relatives first need to learn the practical skills required for the time after hospital treatment.

Follow-up examination

The procedures for follow-up examinations should be agreed with the patient on admission to hospital, including a waiver of medical confidentiality. The possibility of refusing measures taken by the hospital for follow-up examinations should be pointed out.

The data basis for the follow-up examination should be a status report and an assessment of the course of treatment (epicrisis) on discharge.

During the follow-up examination, data on the treatment outcome in the individual treatment case and in relation to the treatment procedure itself must be collected in a planned manner and with a clear evaluation objective. The characteristics of treatment success (indicators or test characteristics) should be carefully selected for the follow-up examination with regard to sensitivity and specificity in order to avoid collecting superfluous data. The recording of events through which systematic errors can be identified must not be left to chance. Even individual data can be the reason for corrective measures. It must be clarified who selects, collects, documents, transmits and evaluates the data and how it is followed up.

The patient does not always have to be called in or physically examined in order to collect suitable data. Other, less complex procedures can be used. In most cases, it is sufficient to ask the patient, the doctor providing further treatment or the aftercare facility.

Procedures for obtaining assessments, complaints, reactions and feedback information that go beyond the medical treatments can be linked to the follow-up examinations.

However, it should always be ensured that serious and unexpected events (side effects and adverse reactions) become known to the hospital and trigger a review of whether corrective measures are required. Appropriate agreements must be made by the hospital with the facilities providing follow-up treatment.

The management must formally define how and by whom the data is to be evaluated and reported on as continuously as possible and with what effects.