Discharge and Transition Management in Integrated Care

Abstract

A key part of integrated care is to ensure a continuous pathway for a patient when being transferred from one healthcare sector to another. Discharge planning and management tries to achieve exactly that. In almost no other part within the care process one can see a clearer clash of different (a) settings and capacities, (b) personal resources and professional cultures, (c) reimbursement and payment schemes, (d) care and medication procedures, (e) usage of (information) technologies, (f) professional cultures and (g) interests. The following chapter describes what discharge management entails, why it is needed in health care systems and in what different ways it can be organized. In conclusion, discharge management is an essential part of providing integrated care in all health systems, but there is still a long way to go to guarantee adequate transitions for patients in most (if not all) health systems.