Due to the fragmented structure of the health organisation in South Africa, there is often difficulty in assuring good co-ordination between in-patient and domiciliary health facilities. This results in the discharge of patients from hospital with poor prospects for the continuity of health care in the community. At Groote Schuur Hospital, approximately 44% of the hospital beds in the white section of the Hospital are occupied by patients in the age group of sixty-five years and over. This group of patients must be regarded as particularly vulnerable with regard to the transition of the care in a hospital to their own home for some of the following reasons: - * The nature of the disease - The chronic and recurrent nature of the degenerative diseases of old age often results in varying degrees of disability. in the aged patient. Many geriatric patients suffer from several unrelated clinical conditions, and thus there is a need to coordinate the many health services required. * Social circumstances - The aged population frequently live alone or with a frail relative, often in poor economic circumstances. * Re-admission rate - The geriatric re-admission rate following discharge is high. As the first principle of geriatric care is to restore independence, and to help patients live away from the hospital environment, the provision of extended care facilities for vulnerable patients is of utmost importance. A structured interview was used to assess the need for extended care facilities of 172 white patients over the age of 60 years who were discharged from Groote Schuur Hospital during March to May of 1981. An attempt was made to evaluate how effectively these needs were being met in the community following discharge. It was found that 34% of the patients interviewed were not getting the nursing care and support in the community which they needed to facilitate rehabilitation. The most vulnerable patients as regards aftercare were: - * The aged * The chronically ill * Patients who live alone or without social support * Patients whose illness leads to temporary or permanent disability * Patients hospitalised for prolonged periods. It was found that the patients interviewed were given insufficient preparation, while still in hospital, for the problems they would be faced with on discharge. No systematic policy exists to ensure that health care staff give adequate information to the patient on discharge from hospital. The ward sister was found to play a vital role in making the preparations for a patient's transfer from hospital to home. A questionnaire was designed to assess the Groote Schuur ward sisters' attitudes towards the importance of discharge planning. An analysis of the ward sisters' response indicated that great variation existed in the attitudes towards the importance of this task. An investigation into the existing community services for geriatric patients was undertaken. An attempt was made to assess the limitations and gaps which exist in the provision of services for the aged. Finally, the role of the recently established Department of Community Liaison at Groote Schuur Hospital was investigated. It was evident that the Community Liaison nurse had proved to be an invaluable member of the health team of a large, specialist hospital such as Groote Schuur. The activities of the Community Liaison nurse led to improved continuity of care for patients needing extended care facilities in the community.