Seamless care

In patient care, smooth cooperation between primary care and the hospital is essential. The hospital admission and the hospital discharge are important pivotal moments for the patient and care workers.

Hospital stays are becoming shorter and shorter and often require (after) care at home. Communication and consultation between the home care sector and the hospital are key factors, and their main goal is to guarantee continuity of care for the person who needs it.

Communication and consultation: nursing consultation

A home care agency can inform the Social Services of the hospital that a person in need of care has been admitted. In preparation for the discharge, the hospital's Social Services can discuss further assistance with the home care agency in good time.

Home Care Team

If necessary, a Home Care Team can be organised for a patient with complex care aspects/extensive home care needs. All those concerned are involved in this together.


The Social Services or the dismissal manager coordinates the dismissal policy.