1. Discharge management: focus on socio- economically and ethnically deprived patients at the postnatal and geriatric ward Research group Integrated Care in Metropolitan area (INCAM Brussels)

2. DEFINITION OF DM The whole of activities carried out by the care providers to assure a good transfer from the intramural to the extramural setting for the patient DM=process in the care trajectory with crucial elements: (1)Evaluation patient needs (before ward admission) (2) Transmural communication (3) Multidisciplinary collaboration (patient education included) (4) Clear written discharge planning in a comprehensive language

3. MOST IMPORTANT RESULTS (1) -In addition to information & education, the patient needs practical & emotional support. -A clear distribution of the caregivers’ roles & tasks at the discharge provides a higher patient’s satisfaction. -Communication & collaboration between the different caregivers (primary as well as secondary health care) who together give form to the discharge, are of decisive importance BUT no discipline claims the coordination of the discharge + no clear coordination role of managing the discharge

4. MOST IMPORTANT RESULTS (2) -Little literature about DM in specific target groups -Differentiation for ethnical and socio-economical groups is very scarce, AND less information -A lot of literature about ED at the maternity ward  A lot of gaps are remaining to be able to pursue an effective discharge policy  More attention should be given to discharge, specifically to the preparation and communication, in particular for specific patient groups.

5.  Discharge planning case manager  The development of transmural and interdisciplinary care paths and protocols  More research needed in this field  Nurses and midwives must be “culture sensitive”

6. CONTACT Florence.dhaenens@ehb.be