Principles of inter-professional cooperation are the basic starting-point for social work at a geriatric workplace (in acute as well as follow-up and long-term care). The article describes our geriatric follow-up care department and its continuity with the long-term care provided by our gerontology centre in the form of nursing homecare, personal assistance, emergency calls and other services. The main purpose of hospitalisation at our geriatric follow-up care department is stabilization of the patient’s health condition, improved self-sufficiency and fast return to the home environment – with the assistance of other follow-up services and organisational and technological measures. After five years of experience at the gerontology centre we receive feedback from our patients and family caregivers to the effect that an important prerequisite for the continuation of care at home is sufficient amount of practical advice and information on all the available options of care and services.
Keywords: social work – counselling – geriatric team – interprofessional team
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General practitioner for adults