Academic Center for Nursing and Midwifery, Department of Public Health & Primary Care, KU Leuven, Leuven, Belgium.
Department of Health Services Research, CAPHRI Care and Public Health Research Institute, Maastricht University, Maastricht, the Netherlands.
BMC Geriatr. 2023 Jan 23;23(1):41. doi: 10.1186/s12877-023-03746-z.
In 2015, a plan for integrated care was launched by the Belgium government that resulted in the implementation of 12 integrated care pilot project across Belgium. The pilot project Zorgzaam Leuven consists of a multidisciplinary local consortium aiming to bring lasting change towards integrated care for the region of Leuven. This study aims to explore experiences and perceptions of stakeholders involved in four transitional care actions that are part of Zorgzaam Leuven.
This qualitative case study is part of the European TRANS-SENIOR project. Four actions with a focus on improving transitional care were selected and stakeholders involved in those actions were identified using the snow-ball method. Fourteen semi-structured interviews were conducted and inductive thematic analysis was performed.
Professionals appreciated to be involved in the decision making early onwards either by proposing own initiatives or by providing their input in shaping actions. Improved team spirit and community feeling with other health care professionals (HCPs) was reported to reduce communication barriers and was perceived to benefit both patients and professionals. The actions provided supportive tools and various learning opportunities that participants acknowledged. Technical shortcomings (e.g. lack of integrated patient records) and financial and political support were identified as key challenges impeding the sustainable implementation of the transitional care actions.
The pilot project Zorgzaam Leuven created conditions that triggered work motivation for HCPs. It supported the development of multidisciplinary care partnerships at the local level that allowed early involvement and increased collaboration, which is crucial to successfully improve transitional care for vulnerable patients.
2015 年，比利时政府启动了一项综合护理计划，该计划导致在比利时各地实施了 12 个综合护理试点项目。试点项目 Zorgzaam Leuven 由一个多学科的当地联盟组成，旨在为 Leuven 地区带来综合护理的持久变革。本研究旨在探讨参与 Zorgzaam Leuven 的四项过渡性护理行动的利益相关者的经验和看法。
这是欧洲 TRANS-SENIOR 项目的一部分。选择了四个专注于改善过渡性护理的行动，并使用滚雪球法确定了参与这些行动的利益相关者。进行了 14 次半结构化访谈，并进行了归纳主题分析。
专业人员赞赏尽早参与决策，无论是通过提出自己的倡议，还是在塑造行动方面提供投入。改善与其他医疗保健专业人员（HCP）的团队精神和社区感被报道为减少沟通障碍，并被认为有利于患者和专业人员。这些行动提供了支持性的工具和各种学习机会，参与者对此表示认可。技术缺陷（例如缺乏整合的患者记录）以及财务和政治支持被确定为阻碍过渡性护理行动可持续实施的关键挑战。
Zorgzaam Leuven 试点项目为 HCP 创造了激发工作动力的条件。它支持了在地方一级发展多学科护理伙伴关系，使早期参与和增加合作成为可能，这对于成功改善脆弱患者的过渡性护理至关重要。
