Übergangsversorgung

Übergangsversorgung, often translated as transitional care, refers to a coordinated set of services and processes that ensure continuity of care for individuals during transitions between care settings, most commonly from hospital to home or to an outpatient or rehabilitation setting. The aim is to prevent gaps in treatment, reduce adverse events, and avoid unnecessary readmissions while supporting the patient’s independence and participation in daily life.

Core elements include early and ongoing discharge planning, interprofessional coordination among physicians, nurses, case managers, therapists and social workers, medication reconciliation, patient and caregiver education, and timely arrangements for post-acute services such as home health nursing, physical therapy, rehabilitation, or home care assistance. In addition, arrangements for home adaptations or required medical equipment, and the seamless transfer of clinical information to primary care providers, are essential components. The process often features a designated point of contact or case manager to navigate the patient through the transition.

Settings and populations most commonly addressed are older adults and individuals with complex or chronic conditions, as well as patients recently hospitalized for surgery, stroke, or acute illness. Transitions can involve hospital-to-home, hospital-to-rehabilitation, or other moves within community-based care networks.

Implementation and funding vary by country and health system. In Germany, discharge management and transitional care are integrated elements of care coordination, with involvement from hospitals, ambulatory care services, long-term care providers, and social services; funding typically involves statutory health insurance and long-term care insurance. Outcomes include improved continuity of care, reduced readmissions, and higher patient satisfaction, though challenges such as fragmented information systems and resource constraints persist.

See also: discharge planning, post-acute care, care coordination.