Figure 1

Common care pathway for transition from hospital and follow-up of home care recipients. The boxes represent procedures and checklists and the arrows the flow of information between involved parties. It starts with the patient being reported as ready for discharge and information is exchanged (1 and 2). Home care services are established (3), and within three days a district nurse performs a thorough and structured assessment (4). The patient has a consultation with the GP 14 days after discharge (5), and a nurse or aide performs an extended assessment during the first four weeks (6). A daily care plan is continuously updated (7), and if the patient’s condition gets worse, the home care service has a routine for what to observe, whom to contact, and which information to pass on (8).