2.5.01 Planning care after discharge

1 Aim and purpose

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1.1 Further outpatient care

Advice, information, organization, 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 Long-term inpatient care

Advice 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 organization is carried out in cooperation with the patient, the ward staff and the social services. The special wishes of patients and their relatives are recognized and taken into account as far as possible. If necessary, care in the home environment is supplemented by further measures.
The prerequisite for the organization 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 arranges for the patient to be cared for at home 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 organize or independently manage 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 advice and accept help. If a patient does not have legal capacity 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.

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