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Geriatric rehabilitation is an interdisciplinary offer of rehabilitation services for elderly persons who often have several impairments and, in some cases, an already existing need for nursing care. It aims at maintaining their self-determined participation in everyday life to the greatest possible extent as well as at avoiding or reducing their needs for nursing care. Characteristic features of geriatric patients are high vulnerability due to an age-related reduction of reserves and often multiple chronic diseases. This is why the geriatric assessment and the multi-professional geriatric team present a correspondingly broad base.As a result of the vulnerability of geriatric patients, early rehabilitation that already starts during acute treatment in hospital is of great importance for their rehabilitative care. Of total German geriatric-rehabilitative care 75 % is inpatient- and 8 % day-care in hospital. These kinds of care are largely provided nationwide. Unfortunately, they often cannot make use of the entire rehabilitation potential of geriatric patients. Independent geriatric rehabilitation facilities, however, are not available in all federal states yet and mainly focus on inpatients. They account for 17 % of geriatric-rehabilitative care - for more than 95 % in connection with a previous hospitalization. Up to now, there has not been an adequate focus on the utilization of out-patient and mobile geriatric rehabilitation as well as on the use of geriatric rehabilitation in case of a slowly progressing deterioration of activities and participation without any acute event. Especially, mobile rehabilitation that is directly performed at the patient's home constitutes a particularly suitable rehabilitation setting mainly for persons who will still need nursery care despite reaching their rehabilitation targets. But this kind of rehabilitation care is still little known.The article provides decision-making aids to physicians in hospitals and doctor's offices as well as information on how to gain access to geriatric-rehabilitative care services, including new regulations to facilitate this access, which are planned for 01 July 2022., Competing Interests: Die Autorinnen/Autoren geben an, dass kein Interessenkonflikt besteht., (Thieme. All rights reserved.)

Geriatric rehabilitation care serves to maintain the self-determined participation of elderly people. It contributes to reduce dependency on care, which is one of society's major challenges. The focus of its work lies on elderly patients, mostly with multiple impairments and limited reserves. These people consequently face a high risk of developing further activity limitations and participation restrictions in the context of any acute illness. This justifies the large proportion of early rehabilitation already in hospital, which forms an essential part of geriatric rehabilitation care in Germany. Its goal is to reduce or prevent any associated setbacks regarding independent living as soon and as far as possible. However, early rehabilitation cannot replace a potentially necessary further medical rehabilitation - particularly under the conditions of lump-sum compensation in the context of the DRG system. But institutions for further medical rehabilitation exist only in some of the federal states in Germany.In addition, geriatric rehabilitation services are largely provided in inpatient settings in Germany. This system to date only rarely takes advantage of the benefits of other forms of rehabilitation. For instance, outpatient geriatric rehabilitation could already be used more frequently to prevent dependency on care in cases of slowly increasing deterioration of functional health. Mobile rehabilitation, where rehabilitation patients are visited in their residential environment, could be more efficient and more sustainable for patients whose rehabilitation and participation goals can be achieved less by means of restitution of lost functions rather than by the adaptation of contextual factors and the improvement of support arrangements., Competing Interests: Erklärung zu finanziellen Interessen Forschungsförderung erhalten: nein; Honorar/geldwerten Vorteil für Referententätigkeit erhalten: nein; BezahlterBerater/ interner Schulungsreferent/Gehaltsempfänger: nein; Patent/Geschäftsanteile/Aktien (Autor/Partner, Ehepartner, Kinder) an Firma (Nicht-Sponsor der Veranstaltung): nein; Patent/Geschäftsanteile/Aktien (Autor/Partner, Ehepartner, Kinder) an Firma (Sponsor der Veranstaltung): nein. Erklärung zu nichtfinanziellen Interessen Die Autorinnen/Autoren geben an, dass kein Interessenkonflikt besteht., (Thieme. All rights reserved.)

Background: Rehabilitative health care is paying increasing attention to multimorbid people with 2 and more coexistent chronic diseases of sociomedical relevance., Methods: Terms, requirements, design, configuration, challenges and supply of sociomedical rehabilitation were described in part I. A project group of the Medical Advisory Board of the Federal Rehabilitation Council describes manifold fields of actions to be taken in the rehabilitation of persons with multimorbidity., Results: The actions proposed range from reviewing existing forms of management to identifying rehabilitative needs and initiating accurately fitting interventions, sensitizing and enlarging competences of involved personnel, considering multimorbidity in guidelines and further research on questions still open., Competing Interests: Die Autoren geben an, dass kein Interessenkonflikt besteht., (© Georg Thieme Verlag KG Stuttgart · New York.)

Background: Rehabilitative health care is increasingly focusing its attention on multimorbid people with 2 and more coexistent chronic diseases of sociomedical relevance., Methods: After defining the term "multimorbidity" in the context of rehabilitative health care, an exploratory overview of the prevalence and clinical implication of this condition as reported in the literature was drafted. Based on a case history, special attention was paid to general as well as special challenges regarding design, configuration and supply of sociomedical rehabilitative care. Consensus was achieved with the Health Advisory Board of the German Federal Rehabilitation Council., Results: The proposed actions necessary for the healthcare of persons with multimorbidity include specific function-oriented individual assessment of needs via the distinctive allocation, selection and performance of rehabilitative procedures as well as post-rehabilitative care until the patient's reintegration into his social environment., Competing Interests: Die Autoren geben an, dass kein Interessenkonflikt besteht., (© Georg Thieme Verlag KG Stuttgart · New York.)

Background: Medical rehabilitation of statutory health insurance (SHI) in Germany aims at prevention of (increasing) disability and thus the need for long-term care. The paper examines the inpatient rehabilitation care utilization in the elderly based on claims data, taking into account the need of pre-existing long-term care (LTC) in according to the German Long-Term Care Insurance and further changes (survival, LTC level)., Methods: Anonymous data from inpatient medical rehabilitation of AOK-insured patients ≥ 65 years (2008/2009) following different treatment pathways were evaluated: early rehabilitation while hospital treatment (FR), combined treatment with early and subsequent rehabilitation (F-/AR), subsequent rehabilitation after hospital treatment (AR); rehabilitation without previous hospital treatment (SR). Survival and LTC-Level (higher level=higher care demands) were tracked for 12 months after utilization of rehabilitation., Results: The extent of pre-existing levels of LTC ≥ 1 was in FR 44.1%, in F-/AR 19.1%, in AR 10.1% and in SR 15.9%. Above-average shares of geriatric indications and below-average shares of orthopaedic indications were observed for all 4 groups. LTC levels remained unchanged for varying percentages of patients in the treatment groups (FR 57%, F-/AR 46%, AR 85%, SR 92%). Higher LTC-Levels were observed for 42% of cases in the FR group, 54% in the F-/AR group, and only 14% and 7% in the AR and the SR group respectively. Lower LTC-Levels could be found in less than 1% of the cases in all groups. Survival rates varied significantly (72% FR, F-/AR 84%, AR 92% and 96% SR). Cases with a pre-existing care level had significantly reduced survival rates. The results could be confirmed after standardization for age and gender., Conclusion: The current application of the legal principle "rehabilitation before LTC" for older insurants is in SHI mainly segmented afterwards or integrated into hospital treatment but rarely combined intersectoral or conducted without immediately preceding hospital-treatment., (© Georg Thieme Verlag KG Stuttgart · New York.)

Background: Geriatric medicine, as a specialized form of treatment for the elderly, is gaining in importance due to demographic changes. Especially important for geriatric medicine is combining acute care with the need to maintain functionality and participation. This includes prevention of dependency on structured care or chronic disability and handicap by means of rehabilitation., Methods and Materials: Ten years ago, the German DRG system tried to incorporate procedures (e.g., "early rehabilitation in geriatric medicine") in the hospital reimbursement system. OPS 8-550.x, defined by structural quality, days of treatment, and number of therapeutic interventions, triggers 17 different geriatric DRGs, covering most of the fields of medicine. OPS 8-550.x had been revised continuously to give a clear structure to quality aspects of geriatric procedures. However, OPS 8-550.x is based on proven need of in-hospital treatment. In the last 10 years, no such definition has been produced taking aspects of the German hospital system into account as well as aspects of transparency and benefit in everyday work., Results: The German DRG system covers just basic reimbursement aspects of geriatric medicine quite well; however, a practicable and patient-oriented definition of "hospital necessity" is still lacking, but is absolutely essential for proper compensation. A further problem concerning geriatric medicine reimbursement in the DRG system is due to the different structures of providing geriatric in-hospital care throughout Germany.

The Health Advisory Board of the German Federal Association for Rehabilitation (BAR) describes future trends and challenges in rehabilitation as deriving from the socio-demographic development in Germany and the structural characteristics of its Social and Health Care Insurance System. The focus is on elder employees to sustain and regenerate their capacity for employment, on people which are no longer employed to activate their autonomy and ability for self-support, and on rehabilitation as a holistic and integrative process extending through the social security and health insurances. There is an urgent need and a real chance to benefit from already existing scientific findings more frequently and to integrate them effectively into adequate further education and training programmes for professionals. Finally the conclusion summarises 8 theses to facilitate rehabilitation as an integral and essential part of the German social security and health sector. This paper was fully accredited by the members of the BAR Managing Board.

The legal survey basis for the hospital statistics of the Statistisches Bundesamt (German Federal Statistical Office) affecting the recording of data starting in the year 2002 has been also adjusted to improve the quality of information on geriatric care structures. The basic hospital statistics data for the year 2003 published in April 2005 report 171 geriatric hospital facilities for in-house treatment and 97 for partial in-house treatment as well as 74 geriatric rehabilitation facilities for inpatient treatment. In an additional internal investigation, another 46 geriatric rehabilitation facilities for outpatient treatment were ascertained for the year 2003. Compared to other, earlier surveys, the Statistisches Bundesamt reports an almost equal number of geriatric care facilities in the hospital sector, but a far lower number of such facilities in the sector of rehabilitation facilities for inpatient treatment, and therefore is highly incomplete. Hence, despite modified recording conditions, the official statistics do not provide a realistic representation of geriatric care structures. Under consideration of these limitations and corresponding corrections, the average geriatric care ratio (inpatient and partial inpatient or out-patient geriatric treatment places in hospitals and rehabilitation facilities per 10,000 persons aged 65 and above) amounted to 10.2 geriatric treatment units in 1997, 12.2 in 2000, and 12.3 in 2003. There were significant differences regarding the total capacity and the shares of different kinds of geriatric care structures in the individual federal states. All in all, that means that the expansion of geriatrics that had taken place until the year 2000 has slowed down significantly over recent years and has largely been limited to demographic adjustments. As far as the relevance of reliable numbers on the existence of geriatric care structures for requirement planning, secondary statistics, and state-related comparative analyses is concerned, the ongoing weaknesses of the hospital statistics must be taken into account when developing corresponding interpretations. They call for examining further improvements of the procedure of recording geriatric facilities for the official statistics. So far, they are no reliable basis for cross-sectional analysis.

The geriatric patient is defined by a high specific risk that is taken into account by the special geriatric treatment concept. This risk relates to suffering from the permanent and significant loss of earlier functional independence caused by relatively trivial accessory conditions or other changes to the personal situation or falling in need of or increasing the need for care. It results from the geriatric patient's limited reserve capacities that are caused by physiological age-related limitations of organ and organ system reserves and/or manifested or at least latent functional impairments. A rather narrow definition of the geriatric patient based on this specific risk is a key criterion for the future systematic integration of geriatric care into the health service. In such a definition, use of the age component alone is adequate only from a very old age on. The high-risk group of geriatric patients narrowly defined in such a way also calls for primary medical geriatric case management: from commencement of a treatment throughout its entire course, from therapy to rehabilitation to longterm and outpatient care. This comprises first and foremost an comprehensive geriatric assessment and a treatment oriented primarily towards achieving quality of life and independence, medical treatment control including a systematic risk management system, continuous patient support, even in case of other temporary, specific treatments, the individual use of early rehabilitative treatments and the coordination of secondary treatment initiatives. Positioning geriatrics in the health care system in such a way means that the required skills extend beyond a general knowledge of geriatric medicine. Above all, high generic treatment expertise and experience in geriatric rehabilitation are also needed. Additionally, the guide and support function of the geriatrician demands a willingness to take special medical and ethical responsibility and an abundant ability to integrate and communicate. The education, training and development initiatives for attaining geriatric qualifications must satisfy these requirements. Lasting efficient geriatric care concepts also call for the appropriate skills in primary medical outpatient care.

The aim of preventive home visits to elderly persons is to reduce mortality, to avoid admissions to nursing homes and hospitals and to improve the functional status and general wellbeing of the elderly. Preventive home visits are rarely a standard service in national health care systems. For over 20 years, controlled randomized studies have been carried out to test their effectiveness. This systematic review evaluates the evidence available on preventive home visits for elderly persons in the context of considerations relating to the incorporation of such a service into the German health care system. Three current systematic reviews (two of them meta-analyses) were identified in a systematic literature survey. They consider a total of 26 studies, most of them RCTs. A further three original controlled studies were identified and evaluated. The original studies were very heterogeneous with respect to goals, target groups, intensity and duration of the home visit programme and with respect to the individuals performing the study (number, profession, qualifications and cooperation). This makes it more difficult to perform a pooled overall evaluation. It was possible to consider mortality, admissions to nursing homes, functional status and psychosocial status as relevant target parameters. The systematic reviews arrive at different assessments of effectiveness. A quantitative, across-studies evaluation demonstrated that preventive home visits to elderly persons were effective both in studies with selected and with unselected inclusion of participants. The second meta-analysis did not confirm this result. Effectiveness here was only demonstrated using stratified analyses which investigated a large number of home visits, the performance of a multidimensional assessment with follow-up visits and the average age and morbidity of participants as relevant influencing factors. However no factor exerted an influence over more than one of the investigated target parameters. The findings thus constitute very unspecific evidence of effectiveness with largely unclear determinants of success. Preventive home visit programmes have been tested in various health systems. Results from controlled (randomised) German studies have not been published to date. The results of studies from other countries have only limited applicability to the conditions in the German health care system because the opportunities for, and extent of, economical and effective improvement in the preventive care of the elderly depend on the standard of care existing in the individual country. The additional value of screening depends on the empirical level of care and not on a given standard. At present the introduction of home visits in Germany cannot be recommended beyond studies. However there appear to be sufficient reasons for controlled studies in Germany which should be carried out in a coordinated way with mutual agreement on concepts.

The Barthel Index (BI) is firmly established as an assessment instrument in geriatrics. It is a proven, clear and easy-to-use instrument for the recording of basic daily functions. However it is increasingly finding new applications beyond its original, clinically orientated use. It has been applied as a quality parameter, as an instrument for the management of service delivery provision and as an instrument to record treatment efforts relevant to care or costs. This study considers the basic suitability prerequisites of the Barthel Index for these applications.With the Hamburg Classification Manual for the BI, German geriatrics has made a contribution to the standardized operationalization of the items and to the standardized evaluation of aids. An evaluation was performed on a total of 5262 Barthel classifications at seven geriatric hospitals according to existing classification practice by comparison with 5483 classifications after introduction of the Hamburg Classification Manual. No significant differences were found in Barthel Index total scores either on admission or on discharge. With respect to further applications it is essential to be aware that the usability of the total score (including its changes over the course of time) is limited because of the ordinal scaling of the BI. Studies have been carried out which show how important this is, although they have so far received little attention. As a grading criterion the BI takes account not only of the "functional status" but also of the "extent of support effort". This can lead to positive changes in one focus -- especially with the use of aids -- without associated improvements in the other focus. Whether the BI in this form is meaningful for a specific application must be tested separately for each individual context. There is no justification for assuming that the BI has general validity irrespective of application. The results of a systematic literature survey on the testing quality criteria of the BI indicate an astonishingly generous approach to the question of the validity of the BI. Contrary to widespread opinion, cognitive-psychological components do influence the classification result of the BI. As an addition to the Hamburg Classification Manual we recommend that the extent of this influencing factor should also be more clearly operationalized and that "stimulation required" for the carrying out of an activity be included in the evaluation equivalent to the factor "supervision required" already introduced by Barthel and Mahoney. The BI has shown itself to be an efficient but nonetheless multidimensional global parameter in clinical practice, whose meaningfulness is on the level of the individual item and whose validity, particularly as total score and course parameter, needs to be proven for each new application. The Hamburg Classification Manual, as a standardized and consensus-based operationalization of the BI, provides an important basis for this.

Every system of payment of flat-rate case charges results in an economically determined optimizing of treatment processes. This presupposes a high level of co-operation between all those involved in the treatment process. Collaboration must extend over occupational groups (doctors, nursing staff and therapists), over departments (specialist geriatric competence and specialist knowledge) and must increasingly take place in a manner extending over sectors (inpatient, partly inpatient and outpatient). To this end, interdisciplinary, team-oriented modes of working provide the direction to be followed in geriatrics. What is essential for efficient patient management is for patient allocation control to be implemented in good time, with individual requirements regarding treatment being provided by the most suitable department. This will only be possible, in perspective, by implementing binding treatment guidelines and quality standards, as well as the timely interdisciplinary incorporation of acute geriatrics, e.g. by participation of the admission wards of the clinics. Geriatrics in acute hospitals has demonstrated its value and has become an indispensable element of appropriate health provision in Germany. The retention of this structure of geriatric care presupposes that, in the future, the DRG system of geriatric services will also be included with a sufficient measure of differentiation and that consequently an appropriate level of remuneration for geriatric services will be ensured. As the DRG system has not been applied internationally, up until now, in the area of acute geriatrics, suitable adjustments to the system of the basic Australian AR-DRG system are absolutely essential.

Quality assurance by documentation in the clinical routine may no longer be regarded as a tedious additional duty providing only little practical value in medical care. This leads to users' resistance and to statistics of doubtful validity. Therefore, the great significance of the primary medical documentation for the quality assurance has to be emphasized and should be the focus of an efficient documentation-management. Requirements for such a documentation-management are described and their implementation in the Albertinen-Haus is shown. This institution uses conventional paper-documents as well as their electronic counterparts. An efficient documentation-management shows the advantage of a quality assurance for the daily routine in hospitals. Data required for the statistical quality assurance should merely be a by-product of the usual documentation. This can only be achieved by an increased computer-support in the clinical routine, but it also requires programmes which fill the needs of all the team members.