Out-of-hospital intensive care – care for those with a critical illness

Some people are so critically ill that their health could deteriorate and become life-threatening at any time. This type of life-threatening situation is a particular risk among people on artificial ventilation (also known as artificial respiration).
A critical illness may therefore mean that the person requires special intensive care by a specially trained nursing professional who is present at all times. Out-of-hospital intensive care allows critically ill people to receive the care they need outside of a hospital setting.

Intensive care is intended to enable early detection and intervention if the health of the care recipient changes and becomes life-threatening. For people on artificial ventilation, a further goal may be to wean off ventilator support, i.e., gradually reduce reliance on the ventilator.

Certain prerequisites must be met in order for a person to be entitled to receive out-of-hospital intensive care: 

• The person has an illness that requires round-the-clock specialist nursing support to enable individual monitoring and operational readiness to deal with any situation that arises.
• It is very likely that life-threatening situations will occur.
• Life-threatening situations could occur at any time, day or night, and without warning.
• Healthcare professionals must be ready to act without delay if a life-threatening situation occurs.

Out-of-hospital intensive care can be prescribed by doctors who specialize in certain fields of medicine and who have a special qualification. These include doctors:

• of internal medicine and lung disease (pneumology)
• of anesthesia
• of neurology
• with an additional qualification in intensive care medicine
• of pediatric and adolescent medicine

Family doctors and doctors specializing in other fields of medicine may also be entitled to prescribe out-of-hospital intensive care. However, to do so, they must have experience in treating ventilated patients or patients using a nasal cannula and must have been granted approval by the National Association of Statutory Health Insurance Providers (Kassenärztliche Bundesvereinigung). 

For people with statutory health insurance, the prescription of out-of-hospital intensive care is regulated in the Out-of-Hospital Intensive Care Directive (“AKI Directive”) published by the Federal Joint Committee (Gemeinsamer Bundesausschuss). Intensive care services have been regulated by this Directive since 1 January 2023. The AKI Directive seeks to improve patient care.

One new condition of the AKI Directive is that a potential assessment must be carried out for all ventilated patients before out-of-hospital intensive care can be prescribed. This assessment investigates whether ventilation can be reduced or gradually phased out or whether the nasal cannula can be removed. In addition, the prescribing doctor must develop a treatment plan. 
According to the AKI Directive, the prescription of out-of-hospital intensive care comprises a number of steps.

In the first step, the prescribing doctor determines whether the person in need of care requires out-of-hospital intensive care. If so, this step is followed by the potential assessment and the development of a treatment plan. 

In many cases, out-of-hospital intensive care is initially prescribed when a person is discharged from an inpatient facility. This may be a hospital or rehabilitation facility, for example. In this case, out-of-hospital intensive care can be prescribed for 7 days. However, a registered doctor in a private medical practice can also issue this initial prescription. An initial prescription by a private-practice doctor is valid for a period of 5 weeks. Follow-up prescriptions can be issued for 6 to 12 months. 

What is checked in the potential assessment? 

A potential assessment is required if the person in need of care is currently on artificial ventilation. However, a transitional regulation is in place until 31 December 2024. Accordingly, patients may be exempted from a potential assessment in certain cases up to that point in time.

The potential assessment is conducted by specialist doctors with a special qualification. The potential assessment examines various aspects of the patient’s health, including:

• breathing movements
• cough strength
• state of consciousness
• pain intensity

Based on the test results, the doctors determine whether the time for which the patient is ventilated can be reduced or whether the patient can be weaned off artificial ventilation or use of a nasal cannula. They also assess the development of the disease, the prospects for improvement, and the quality of life of the person in need of care.

The potential assessment can also be conducted using telemedicine solutions. In other words, the assessment may be conducted at a physical and possibly also temporal distance, for example, via telephone, apps, or the Internet. However, the assessment must be conducted in person at least once per year. In certain cases, exceptions may be made to this rule. 

The aim of the potential assessment is to improve the treatment of the person in need of care. The result of the potential assessment must be no more than 3 months old at the time the prescription is issued. If it is likely that ventilation cannot be reduced for the person in need of care, the result of the assessment must be no more than 6 months old. The assessment must be repeated every 6 months. 

What is contained in the treatment plan?

The aim of the treatment plan is to ensure that the care provided to patients can be organized in the best way possible. This is important because out-of-hospital intensive care measures often involve professionals from various disciplines. These may include healthcare professionals, physiotherapists, or suppliers of medical products, for example. 

The personalized treatment plan is developed by the prescribing doctor. The treatment plan lists all measures required by the person in need of care. Examples of out-of-hospital intensive care measures are listed below:

• monitoring of the person’s health status by measuring heart rate, blood pressure, or breathing rate
• initiating and executing emergency measures
• operating and monitoring a ventilator and using a respiratory mask
• correct care of the tracheostoma (the artificial connection to the trachea) or nasal cannula
• measures to remove excessive fluid or mucus from the airways
• measures to monitor and improve the patient’s ability to swallow 
• training the patient’s loved ones to be involved in their care

Where are applications for out-of-hospital intensive care submitted?

As a next step, the person in need of care or one of their loved ones submits the application for out-of-hospital intensive care to the relevant health insurance provider. The insurance provider tasks the Medical Review Board to review the applicant’s entitlement to out-of-hospital intensive care. The health insurance provider covers the costs of intensive care services until the Medical Review Board has reached a decision. It is essential, however, that the prescription be submitted to the health insurance provider no later than 4 working days after it is issued.

Who coordinates the intensive care on an ongoing basis?

The prescribing doctors oversee cooperation between all involved and update the treatment plan on an ongoing basis. The prescription can be extended if necessary.

Intensive care services can be provided in different locations. The location for the intensive care depends, for example, on the needs of the care recipient and on the services available.

Out-of-hospital intensive care may be provided in the following locations: 

• at home
• in group homes with ventilator support or other supported living arrangements
• in residential care facilities
• in schools, kindergartens, and workshops for people with disabilities 

How can I find a suitable facility?

The regional associations of the health insurance funds conclude contracts with providers of out-of-hospital intensive care. One way to find a suitable facility is to consult the prescribing doctor and the relevant health insurance provider. Care support points can also assist in the search for a suitable facility. 

To find a care support point close to where you live, refer to the Center for Quality in Care (Zentrum für Qualität in der Pflege) foundation.

Further information can be obtained from the German Interdisciplinary Society for Non-Clinical Ventilation (Deutsche Interdisziplinäre Gesellschaft für außerklinische Beatmung e.V., DIGABR).

Another useful source of information is the Care Guide (“Pflegelotse”) information portal operated by the Association of Substitute Health Insurance Funds (Verband der Ersatzkassen, VDEK).

Statutory health insurance providers cover most of the costs associated with out-of-hospital intensive care. If intensive care is provided in a residential facility, the health insurance provider covers the following costs:

• costs of medical post-treatment care
• care-related costs
• operational investment costs
• costs of accommodation and meals

If the person’s health improves and out-of-hospital intensive care is no longer required, the health insurance provider is still required to cover the costs for a further 6 months. However, this only applies if the person has a need for care with an assigned care grade of 2, 3, 4, or 5. 

The care recipient is required to cover the costs of accommodation and meals if receiving care at home or in a care group home. 

Are co-payments required for intensive care?

People over the age of 18 are required to pay co-payments. If intensive care is provided in a nursing home, a co-payment of 10 euros per day is required. The total contribution is limited to 28 days per year.

If intensive care is provided in the person’s own home or in a similar location, the co-payment amounts to 10 percent of the daily care costs. In addition, 10 euros must be paid for each prescription. The total contribution is similarly limited to 28 days per year. 

Co-payments are only to be made up to the value of 2 percent of the person’s gross annual income or, for those with a chronic illness, 1 percent of their gross annual income.

Only specially qualified doctors are authorized to prescribe out-of-hospital intensive care and conduct potential assessments. 

In principle, doctors specializing in lung disease (pneumology), anesthesia, neurology, and pediatric and adolescent medicine with an additional qualification in intensive care medicine are authorized to prescribe out-of-hospital intensive care. You can search for these here:
Search for prescribing doctors

A search function is also provided to help you find doctors who are approved to conduct a potential assessment and issue a prescription:
Search for doctors for potential assessments and prescriptions

In addition to affiliated doctors’ practices, specialist hospitals and other doctors may also be authorized to conduct a potential assessment – see:
Overview of providers (PDF)

Ask in the practice directly whether out-of-hospital intensive care services are prescribed.

Sources of more detailed information about the topic of out-of-hospital intensive care are listed below: 

The Federal Joint Committee (Gemeinsamer Bundesausschuss, G-BA) has published the Out-of-Hospital Intensive Care Directive on its website.

The website of the National Association of Statutory Health Insurance Physicians (Kassenärztliche Bundesvereinigung, KBV) provides information aimed primarily at healthcare specialists.