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Care transition at the University Hospital

We are certified nursing staff who also have experience in outpatient nursing. We are therefore familiar with the living environment of patients and their relatives at home. We know the possibilities and limits of care within our own four walls. We prepare the home environment so that further care at home can be continued without interruption. This is done together with patients, relatives and other parties involved. It is important to see and activate resources. We clarify the need for help and initiate the necessary steps in planning and implementation.

There is a wide range of support services available to ensure that people stay at home as long as possible. A supporting pillar are the outpatient nursing services.

  • mobile food service, e.g. meals on wheels
  • Home emergency call systems
  • Household service
  • mobile social services (e.g. DRK or CBF transport services)
  • Discussion groups for caring relatives
  • Self-help groups
  • Care courses and training for relatives
  • voluntary care and support services, e.g. local hospice group
  • Social Psychiatric Service
  • Care support point

Both are benefits of the nursing insurance, which means that the patient must have at least nursing level 2.

Day care is a semi-inpatient care service, i.e. during the day those in need of care are cared for in an inpatient facility (e.g. nursing home).

Assisted living complexes offer barrier-free, elderly-friendly apartments with care service. This offer is suitable for senior citizens who want to live independently, but have help available in case of emergency.

How can the apartment be adapted to suit the elderly or disabled?

For people with considerably limited everyday skills. The care services that must meet the corresponding criteria include in particular care groups, individual care, day care.

Some outpatient nursing services offer a presence to look after the relatives to be cared for (or those suffering from dementia) at home. Also over 24 hours or overnight. Prices must be obtained from the provider.

If aids are needed at home after the hospital stay, such as wheelchair, nursing bed, etc., the staff of the nursing transition department will advise on these aids and their financing. The medical certificate for this can be issued during the hospital stay, so that the necessary aids are available upon discharge.

Tübingen project

Tübingen project

The Tübingen project is a specialised palliative service for the home care of seriously ill and dying people, in particular tumour patients.

Frequently asked questions about the transition to nursing care

The actual accompaniment of the patient and relatives is limited to the stay in the clinic. However, we offer to be there as a contact person for questions even after discharge.

No. The transfer service is free of charge for patients and relatives.

The care transition team acts as a mediator and advisor. The jointly discussed planning of needs and discharge should be understood as an aid to ensure that care at home is provided as well as possible. Both are benefits of the nursing care insurance, which means that one must have at least nursing degree 2.

Yes. The arrangements for home are embedded in the given structures. Of course, a good cooperation with the family doctor is important.

The nursing transition is part of the Social Counselling and Discharge Management Department. It works closely together with the colleagues of the social counselling department. The department reports to the Directorate of Nursing. Assisted living facilities offer barrier-free, age-appropriate apartments with care services. In other words, for senior citizens who live independently but want to have help available in case of emergency.

As certified nursing staff, all members of the team have experience in outpatient nursing. Appropriate additional qualifications (e.g. certified nursing economist, certified case management, nursing pedagogy) underline the competence of the team.

The employees of the nursing transition department come into the patient's room to talk. Alternatively, a sitting area or a room on the nursing ward can be chosen.

Certificates and Associations

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