Transitional care in hospital
Hospitals are often confronted with the problem that treatment is no longer medically necessary and the patient should actually be discharged to rehabilitation or a nursing home. However, places in rehabilitation facilities and nursing homes are scarce, so patients increasingly remain in hospital until a place becomes available. However, these costs are not covered by the health insurance fund; instead, the health insurance funds or the MD are criticized for incorrect occupancy.
With regard to follow-up care in medical rehabilitation, the BSG stated in its ruling of 19.11.2019 (B 1 KR 13/19 R) that if the insured person no longer requires inpatient hospital treatment, but inpatient medical rehabilitation treatment is required without interruption and the rehabilitation provider does not provide a place, the hospital has a claim for remuneration for the inpatient emergency medical rehabilitation against the rehabilitation provider. Other legal regulations did not previously exist, which is why the patient's entitlement to transitional care has now been added to Section 39 e SGB V, which has been in force since 20.07.2021. This enables the insured person to claim the costs of transitional care in hospital for a maximum of ten days from the health insurance fund.
1. requirements for entitlement to transitional care
The prerequisite for this entitlement is that the patient can be discharged, but that the necessary home nursing care services, short-term care, medical rehabilitation services or care services in accordance with SGB XI cannot be provided immediately after hospital treatment, or can only be provided at considerable expense.
What is meant by the term "only with considerable effort" will lead to problems in practice. Originally, the wording "only at unreasonable expense" was to be included, but this was abandoned after the German Hospital Association criticized this wording. However, the concept of unreasonable effort was not specified in the explanatory memorandum to the law - as requested by the German Hospital Federation. The explanatory memorandum merely points out that patients cannot be required to make a considerable effort to secure care elsewhere.
For example, the fact that a short-term care place is available at a considerable distance would not prevent the claim. (BT - Printed matter 19/30560, p. 27, on no. 13 a)
It remains to be seen whether the envisaged regulations on verifiable documentation in accordance with Section 39 e (1) sentence 5 SGB V will contain more specific details
2. more detailed definition of the depth of documentation required
The existence of the requirements for transitional care must be documented in detail by the hospital in a verifiable manner (§ 39 e Para. 1 S. 4 SGB V).
However, the form that such documentation should take is still to be regulated on a nationwide basis. The National Association of Statutory Health Insurance Funds, the Association of Private Health Insurance Funds and the German Hospital Federation have until October 31, 2021 to agree on the details (Section 39 e (1) sentence 5 SGB V). If they are unable to meet this deadline, the arbitration board in accordance with Section 18a (6) KHG will determine the content of the agreement within six weeks without an application from one of the contracting parties (Section 39 e (1) sentence 6 SGB V).
As part of discharge management, hospitals are already recommended to document in as much detail as possible that there is a specific need for follow-up care and that no corresponding service provider is available or that care cannot be secured in any other way.
Clear guidelines for documentation may still be a long time coming.
3. remuneration issues not yet clarified
The question of remuneration for transitional care is also still completely open.
Section 132m SGB V (new) was also introduced with the new Section 39e SGB V. This contains a provision that associations of health insurance funds and hospitals should conclude contracts at state level on the details of the provision of transitional care services in accordance with Section 39e SGB V and their remuneration.
However, no deadline has been set for the contracting parties to reach an agreement. It is merely stated that in the event of a failure to reach agreement, the content of the contract will be determined by the arbitration board in accordance with Section 18a (1) KHG at the request of one of the contracting parties within three months.
4. conclusion
The entitlement to transitional care therefore still requires some further specification. In addition to documentation and remuneration, it is hoped that the term "at considerable expense" will also be defined in more detail. Otherwise, disputes are inevitable, as this vague term will be a gateway for the health insurance funds and the MD to make accusations of incorrect occupancy.
Status: 23.09.2021