Sozialmedizinische nachsorge für schwer und chronisch kranke kinder: Eine neue leistung der krankenkassen

Coordinated ambulatory aftercare of children and adolescents with severe and chronic conditions will improve the transition from inpatient to outpatient care. Aftercare professionals network within and outside the aftercare team, coordinating services and educating and counselling parents, family members, and professionals. They support adaptation and coping processes, accompany the parents to other welfare and health care services, and empower families to access needed services. Aftercare follows the principles of case management and includes home-based services and home visits. Social medical aftercare is supported by the German health insurances, so care providers must be certified and accredited in order to be reimbursed. The aftercare concept described here, called "Bunter Kreis" (Colourful Circle), has been scientifically evaluated, accredited by the health insurance and health boards, and serves as a model for over 47 aftercare organizations in Germany. These organisations are connected in a quality network, "Qualitätsverbund Bunter Kreis".