If three or more check marks are obtained, an interdisciplinary decision* should determine whether the patient is to be offered post-discharge follow-up visits. The interdisciplinary decision should be made in dialogue** with the municipality whenever possible.
*In the interdisciplinary decision, the following elements should be taken in to account:
• Nursing needs as well as medical needs.
• Magnitude of individual problems.
**Applies in situations where the dialogue with municipal staff has already been obtained, i.e. planning meetings.”