KV RegioMed Zentrum Templin

Templin – Uckermark - Brandenburg
Target group:
Multimorbid patients aged 65+ and their informal carers

In response to massive demographic change in rural Brandenburg, in 2014 an innovative care concept for older patients has been put in place in the Uckermark district, situated in the Northeast of Brandenburg. Housed at a local hospital in the town of Templin (16,000 inhabitants (2011), 23% of whom are 65+), the innovative programme offers intensive outpatient geriatric coaching for older patients with complex needs. With its Complex Therapy programme, KV RegioMed Zentrum Templin follows a preventive and rehabilitative approach aimed at strengthening the patient’s own coping capabilities. For three weeks, patients visit the practice spezialized on elderly people

on a daily basis. While receiving care and supportive therapy, programme participants learn about their medication plan, fall prevention, and a healthy diet and lifestyle. For each patient a personal, tailored care plan is developed, and guidance to professional and voluntary services in the community is also provided. During their time in the programme,  patients are supported by the “Agnes two” Case Manager (a specially trained practice assistant). However, a lot of patients do not get any support after having completed this 3 week programme.

The improvement project is a newly set-up Coordination and Consulting Centre (“Service Center”), which will be the central contact point regarding care issues for patients in the region. These services will not be exclusively for patients from the KV RegioMed Zentrum in Templin but are open and accessible to patients from other medical services in the region.


Pflegewerk (Careworks Berlin)

Berlin Marzahn-Hellersdorf
Target group:
Older, chronically ill people with long-term care needs as well as those affected by social isolation that comes with living alone

Careworks Berlin is aimed at improving the care of older people with complex health and long-term care needs. Careworks Berlin is already highly innovative and integrated in that it combines long-term condition (LTC) case management, discharge management, and palliative care under one roof.

The purpose of the SUSTAIN improvement project (“Therapy Pilots”) is to enhance inter-professional case management, creating synergies between therapists, nurses and informal carers, while putting healthcare therapists (i.e. physical therapists / speech therapists / occupational therapists  etc.) into the driver’s seat. This is an explicit transfer of prescribing practice to health care therapists according to the Social Code Book for Health (SGB V); § 63 SGB V, para 3b. This new role of health care therapists is aimed at improving multidisciplinary collaboration between medical doctors and health care therapists, allowing greater therapeutic involvement of  non-medical staff.