Eftirfylgd

Eftirfylgd, or aftercare, is a planned process of follow-up support provided after initial treatment, discharge from a hospital, release from a detention facility, or completion of a treatment program. The purpose is to ensure continuity of care, monitor health status, support rehabilitation, and reduce the risk of relapse, complications, or readmission.

It spans multiple sectors, including medical and surgical aftercare, psychiatric and addiction services, chronic disease management, rehabilitation, social services, and education. Typical elements include an initial assessment, a personalized care plan, scheduled follow-up appointments, home visits or telehealth contacts, medication management, coordination with primary care and specialists, and access to community resources. Involvement of family or carers is often encouraged when appropriate.

Delivery models vary but commonly involve discharge planning teams, community-based case management, and integrated care pathways. The goals are to improve continuity of care, support functional recovery, increase adherence to treatment, and reduce hospital readmissions and social disengagement. Evidence on effectiveness is variable and depends on resources, planning quality, and coordination across services.

In Iceland, as in many developed health systems, aftercare is typically organized through primary health care services and municipal social services, with coordination among hospitals, family physicians, and social workers. Policies emphasize person-centered planning and smooth transitions from inpatient to community-based care.