THE GERIATRIC TEAM IN PREDISCHARGE AND PO STDISCHARGE NURSING AND THERAPEUTIC CARE

The transition team has its place in pre- and postdischarge nursing an d therapeutic care, on the basis of a geriatric assessment. Core membe rs of the team are, in the sequence of the scheduled performance in-ho spital, nurse, occupational therapist, physiotherapist and social work er, supplemented by a team physician. Two-thirds of all treatments wer e in the hospital, one-third in an outpatient setting up to 4 weeks af ter discharge. Cooperation with outpatient services has been good.