Expert standard discharge management in nursing care

Breaks in care manifest themselves particularly during the transition from inpatient to post-inpatient care. They lead to unnecessary stress for those affected and their relatives, and the associated "revolving door effects" imply a waste of the already very scarce resources in the healthcare system. (From the preamble to the expert standard)

The shortening of lengths of stay with the introduction of DRGs has led to enormous change in the healthcare sector with considerable momentum. Furthermore, the increase in older, chronically ill and multimorbid patients is presenting clinics with ever greater challenges.
Since 2017, there has been a framework agreement on discharge management during the transition to care after hospital treatment in accordance with Section 39 (1a) sentence 9 SGBV V (framework agreement on discharge management) between the National Association of Statutory Health Insurance Funds and the National Association of Long-Term Care Insurance Funds, Berlin, the National Association of Statutory Health Insurance Physicians, Berlin and the German Hospital Federation, Berlin.
This means that hospitals are legally obliged to establish a discharge management system.
Care disruptions can only be avoided if patients' care needs are identified at an early stage (at the beginning of inpatient admission) in order to be able to organize and coordinate post-inpatient care in line with patients' needs. Interdisciplinary cooperation and the involvement of all stakeholders (internal and external) are essential prerequisites for this.