Abstract
INTRODUCTION: Continuity in information and care at the interface between inpatient and outpatient sectors is not always guaranteed. The aim of the study was to develop a funding concept to improve transitional situations such as admission and discharge from inpatient care and to meet the coordination needs of patients with complex diseases or multiple risk factors. METHODOLOGY: Conceptual foundations to support cross-sectoral cooperation were developed by the Bavarian State Working Group on Health Services Research (LAGeV). RESULTS: New forms of cooperation in the outpatient and inpatient sectors should promote intersectoral care networks and modules to foster patient-centered communication and coordination of care. This includes setting up case management systems to support coordination at sectoral interfaces. In the present study, the following modules are explained in more detail: integrated care paths, discharge management, inter-sectoral quality circles, structured pharmacotherapy, involvement of the nursing and rehabilitation sector, and health promotion and prevention. Finally, the importance of systematic and comparative evaluation of the intersectoral networks is discussed. CONCLUSION: To provide effective impulses for the improvement of intersectoral cooperation, a funding concept should include targeted modules to improve patient-centered care at the interface between the inpatient and outpatient sectors. Systematic evaluation should be compulsory, using both generic quality indicators and network-specific targets.