[Selected results of an evaluation study on a Viennese model project: discharge management in hospitals by home care nurses--the view of patients and their families].

In recent years, demographic developments, changes in the financing of hospitals as well as demands for integrated care approaches by health and social policy makers have brought the issue of an improved hospital discharge management to the forefront. The article discusses results of an evaluation study of a Viennese model project on indirect discharge management at the Kaiser-Franz-Josef-Hospital in Vienna. The service coordinated at hospital level is provided by ambulant nurses for specific wards of the hospital. The data of the study show that the target group consists primarily of old patients with multiple illnesses requiring home care services as well as patients being transferred to nursing homes. The evaluation proves that patients and their families are highly satisfied with the service. Dedicated contact persons really provide crucial support to patients and relatives in this emotionally distressed transitional period, seeing their clients through difficult decisions. Discharge managers and clients jointly find out actual needs of the patient and discuss possible solutions considering available resources of the respective lay system and ways to strengthen it. The outcome is a tailor-made care package, coordinated across professional services, matching the patients' needs and resources. Moreover the study illustrates that concepts of transitional nursing care require extraordinary skills and competences on the part of the discharge manager, currently not covered by the Austrian curriculum for nurses.