Figure 1. Activities of the Integrative Hospital Treatment in Older Patients to Benchmark and Improve Outcome and Length of Stay Study Along the Patient Transition Pathway.

Step 1 included an early discharge date estimation done by the emergency care team; step 2 involved a systematic assessment of delaying factors (diagnostics and therapy) during hospital stay, a modification of the potential discharge date, and an early assessment and contacting of postacute care facilities; step 3, physicians and nurses performed a timely discussion of pending in-hospital tests, out-of-hospital appointments, changes in medication plan, and strategies in case of clinical worsening at home with patients and relatives. Patient comprehension was assessed using the teach-back methodology. Information was recorded by either physicians, nurses, or social workers and was immediately available to all involved professionals using the EMR.