Transition to out-of-hospital intensive care (außerklinische Intensivpflege).
A ventilated person or a person with a tracheostomy leaves the hospital and continues to be cared for at home. We take on the part that otherwise falls to the social service and to family members: prescription, medical aids, equipment training, transport and feedback – in the Lower Rhine region, the Ruhr area and the Rhineland.
What has to come together in the transition to intensive care
Transition in out-of-hospital intensive care (außerklinische Intensivpflege) means: a person who is permanently ventilated or has a tracheal cannula leaves the hospital and continues to be cared for at home. Many threads come together for this: hospital, health insurance fund (Krankenkasse), medical aids provider, pharmacy, general practitioners and specialists, therapists and family members. If the care service does not take over this coordination, it ends up with the social service or the family.
Since the AKI guideline under § 37c SGB V, the process has become more demanding: the prescription may only be issued by a specially qualified physician, and before that comes the potential assessment, i.e. the medical review of whether weaning or decannulation is possible. If one component is missing, discharge is delayed by weeks.
Our transition coordinator keeps all components together and is the same contact person for the hospital, family members and physicians, from the first call to the status report after takeover.
What we take on in every transition
- Case conference at the hospital with professional assessment
- Prescriptions 62A, 62B and 62C pre-filled and checked before sending
- Medical aids ordered, appointments set, delivery tracked
- Equipment training for team and family members organised
- Medication clarified with the pharmacy, blister packing arranged
- Patient transport booked, client picked up from the hospital
- Written status report to your discharge management
Three commitments your discharge management can rely on
No blanket promises, but three deadlines that we keep in every transition.
First appointment guaranteed
No later than 48 hours after your request, we sit down with you, the client and family members, at the hospital or in rehab.
Medical aids list with the provider
No later than 24 hours after the first appointment, everything is ordered, even if the insurance fund has not yet approved. You receive the delivery confirmation in copy.
Discharge as planned
Your discharge date will not fail because of the aids required for discharge. Delivery is made by the agreed day, and the first shift is on site before the client arrives.
Five steps, one contact person
From the first call to the status report, the same transition coordinator remains responsible, for social services, relatives and physicians.
Day 0 · Case notification
You call us or write briefly with the discharge date and place of care. On the same working day we get back to you and tell you who your transition coordinator is.
Day 0 to 1 · Initial assessment
We check capacity and professional feasibility. You learn immediately, not after weeks, whether we can take the case. A commitment from us is reliable.
Day 1 · Prescription and aids
The list of aids and devices goes to our providers within 24 hours. At the same time, we support the prescribing physician with forms 62A, 62B and 62C.
Until discharge · Preparation on site
We get to know the client and relatives in the hospital, look at the home, organise the device training and coordinate the medication with the pharmacy.
Discharge day · Takeover
We pick up the client at the hospital and accompany them home. Care runs from the first hour. Afterwards you receive your status report for the file.
Hospital-level intensive care in your own home
We care for adults with intensive care needs at home, 1:1, with permanent care teams of our own skilled staff.
Ventilation and tracheostomy
Invasive ventilation via tracheostomy, non-invasive mask ventilation, tracheostomy without ventilation, prolonged weaning after unsuccessful weaning in a weaning centre, chronic respiratory insufficiency in COPD, secretion management for weak cough.
Neurological and other conditions
ALS, muscular dystrophy, post-polio, high spinal cord injury requiring ventilation, traumatic brain injury, state after hypoxia, vigil coma, critical illness polyneuropathy after long intensive therapy, dysphagia with PEG feeding.
To what extent
24-hour care with 1:1 support around the clock, partial care with fixed hour allocations, for example for night shifts, or transitional care until another form of care begins. The prescribing physician determines the extent, and we discuss it with you beforehand.
Transition from three perspectives
Discharge management, relatives and physicians need different things in the transition. We take all three on board.
Social services and discharge management
Of the eight work steps that otherwise fall to social services in a ventilation transition, we take over seven. You decide when the client is discharged, and you receive copies of all documents for your file.
More for referrersFamily members
You want to know what the day of the homecoming looks like, who comes and who bears the costs. We explain every step, train you on the equipment and are available to you around the clock afterwards.
Request consultationGeneral practitioners and specialists
You prescribe in accordance with the AKI guideline and bear medical responsibility. We provide pre-filled forms 62A to 62C and coordinate the appointments for the potential assessment. No influence, no referral fees.
One name, one face, one responsibility
Christian Altmann heads our care service and is a specialist nurse for anaesthesia and intensive care. As transition coordinator, he takes in your case, sits at the table at the case conference in the hospital and remains your direct contact until the status report – no hotline, no changing contacts.
Directly reachable
One direct line for social services, family members and doctors, from the first call to the takeover.
Professional at the bedside
He personally records the ventilation status, cannula, medication and the family's wishes at the hospital.
Closes the loop
After the takeover, he reports to your discharge management in writing: cared for, submitted, running.
Questions about the transition to intensive care
What does transition mean in out-of-hospital intensive care (außerklinische Intensivpflege)?
Transition is the organised move of a person requiring intensive care from a hospital, weaning centre or rehabilitation clinic to care at home. It includes the medical prescription, cost coverage by the health insurance fund (Krankenkasse), ventilator and aids, medication, transport and a care team that is ready on the day of discharge.
How early should we get in touch?
For a smooth transition we usually need two to three weeks, mainly because of delivery times for aids and ventilation technology. Under § 10 Abs. 4 AKI guideline, the hospital generally informs the health insurance fund (Krankenkasse) at least 14 days before the planned discharge. It is best to report the case to us at the same time. If home care is already in place, it goes much faster.
Who may prescribe out-of-hospital intensive care (außerklinische Intensivpflege)?
Under the AKI guideline, only specially qualified physicians, for example from pulmonology, anaesthesia, intensive care medicine or neurology. In discharge management, the hospital issues the prescription, which is valid for up to seven calendar days after discharge. After that, a qualified contract doctor takes over the follow-up prescription. We look for this doctor before discharge and prepare the documents; the decision and signature remain with the doctor.
What is the potential assessment under form 62A?
Before the prescription, a qualified doctor checks whether weaning from ventilation or removal of the tracheal cannula (decannulation) is possible. The result is recorded on form 62A and must not be older than three months at the time of prescription. Because there are too few doctors for this, the transition often stalls here. We coordinate the appointments through a network of qualified doctors. We do not carry out the assessment ourselves.
Who bears the costs of out-of-hospital intensive care (außerklinische Intensivpflege)?
Care under § 37c SGB V is a benefit of the health insurance fund (Krankenkasse). We clarify cost coverage before care begins, submit the prescription with power of attorney to the fund on time and handle the communication. The statutory co-payment for adults is 10 percent of the costs plus 10 euros per prescription, limited to the first 28 days in the calendar year. We charge no additional payments beyond that.
What must be ready at home on the day of discharge?
Ventilator with a second device and battery, suction, humidification, oxygen, monitoring, emergency equipment with a spare cannula and ventilation bag, a feeding pump for PEG, a care bed and positioning aids, plus consumables for the first days. Also a space with enough power sockets and access for the emergency services. We handle ordering and delivery, and we look at the home together beforehand.
How do you ensure the care team is in place?
The staffing is set before the client is discharged. Care with us usually involves five to nine registered nurses (Pflegefachkräfte) whom the client knows by name. We work without temporary agency staff and only accept as many cases as we can staff with our own personnel. Every nurse is briefed on the client and the equipment before starting.
What happens if it doesn't work out at home?
That is what our 24/7 emergency and readmission concept is for: the care team is on site around the clock, a written emergency plan covers cannula and ventilation incidents and power failures, and the transition coordinator remains reachable. If the patient's condition worsens, the way back to the hospital is arranged, and we tell the hospital without being asked which prescription is in effect.
In which region do you handle transitions?
In the Lower Rhine, the Ruhr area and the Rhineland, from our base in Alpen. This includes, for example, Wesel, Xanten, Rheinberg, Moers, Kamp-Lintfort, Geldern and Sonsbeck. We will tell you on the first call whether we can care for your location and whether we currently have capacity.
Is a discharge coming up?
Tell us the discharge date and the place of care. Your transition coordinator will get in touch on the same working day, and within 48 hours at the latest we will be sitting down together.
info@open-care-intensiv.deInsured persons' freedom of choice and the physician's authority over therapy and prescriptions remain unaffected by our service. We prepare, but we never prescribe or issue anything ourselves.