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The concept of medical transfer management means the targeted transfer of patients from the inpatient (hospital) setting to the home environment. Specialised palliative care nurses take on the care, counselling and support, and optimising the health care of terminally ill patients. This focus aims to allow patients to stay in their own home as long as possible and still receive all necessary treatments. Medical transfer management coordinates the fast transfer from the hospital to the home. It better allows the connection between hospital and home (through case management and integrated service delivery) and also manages all aspects of palliative care. Competent staff ensure 24 hour support and thus provide patients and their relatives with the necessary level of security. The close teamwork of all involved medical staff, social workers, nursing services and ambulatory hospice services, ensures that the home care is optimised and admission to hospital is restricted to absolutely necessary visits.

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