Fig. 2.

The “In-HospiTOOL”. An integrative patient management tool. The “In-HospiTOOL” has three components involving admission (inter-professional initial assessment, “Ersterfassung”), medical ward (inter-professional daily re-assessment, “Visitentool”), and discharge (inter-professional patient education, reengineered discharge [32]). PACD, Post-Acute Care Discharge [15, 18]