2.5.01 Planning care after discharge

1 Aim and purpose

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The measures required for planning the patient's care after discharge from hospital must be described in a procedural instruction. Medical, nursing and special social aspects must be taken into account (involvement of social services). Planning begins on admission to hospital.

1.1 Further outpatient care

Advice, information, organisation, mediation for the continued care of patients in their home environment after discharge from hospital. Establishment of a sustainable outpatient support system or reintegration into existing care structures to ensure the success of medical treatment.

1.2 Inpatient long-term care

Counselling and information for patients and relatives about short-term care or permanent inpatient care in an appropriate facility, such as a nursing home or hospice. Support in finding a place in a nursing home, hospice or short-term care facility, taking into account the wishes of the patient and their relatives. Planning and organisation is carried out in cooperation with the patient, the ward staff and the social services. The special wishes of patients and their relatives are recognised and taken into account as far as possible. If necessary, care in the home environment is supplemented by further measures.
The prerequisite for the organisation of aftercare is the direct discharge of the patient from the HOSPITAL. If a patient is transferred to another hospital or discharged to a rehabilitation clinic, this facility organises care in a home environment or in long-term care.

2 Application

These procedural instructions apply to patients who require temporary medical treatment care and/or further outpatient care or long-term inpatient care after discharge because they are unable to organise or independently perform their personal hygiene, nutrition and housekeeping. For long-term inpatient care, there must be a need for residential care within the meaning of long-term care insurance.
The basis for this is the willingness of the patient and, if applicable, their relatives to seek counselling and accept help. If a patient is not legally competent within the meaning of guardianship law, the requirements under guardianship law must be met before aftercare is initiated (see point 6.2). The guardianship law must be observed here and a significant delay in discharge is to be expected in individual cases. Users are the social services, the medical service and the nursing service.

9 Applicable documents

9.1 Literature, regulations

Section 11 (para. 4) SGB V states: "Insured persons are entitled to care management, in particular to solve problems during the transition to the various areas of care; this also includes follow-up care by specialists. The service providers concerned shall ensure that the insured person receives appropriate follow-up care and provide each other with the necessary information. They are to be supported by the health insurance funds in the fulfilment of this task. Care facilities must be involved in care management; close cooperation with care counsellors in accordance with Section 7a of Book Eleven must be ensured."

9.2 Terms

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