[Transmural collaboration in palliative care: a feasibility study into structured transfer of care for acutely hospitalized patients].

Abstract

Objective: Care transitions are common in the last months of life and continuity of information and care is at risk when unplanned admissions are necessary. To mitigate the risk of inappropriate care, a transmural care pathway was developed, that includes active involvement of a patient's general practitioner during hospitalization.

Design: Multiple-method feasibility study in an academic hospital and affiliated general practices from July to December 2022. Data collection involved a survey and semi-structured interviews. Analysis encompassed descriptive statistics and thematic analysis.

Results: Patients (n = 41) with cancer who experienced an unplanned hospital admission were included. The study shows that personal contact and the use of a scripted protocol during care transitions improves collaboration between healthcare professionals. Balancing attention between the physical, psychological, social, and spiritual dimensions of patients remains a challenge.

Conclusion: Personal telephone contact with a patient's GP during hospital admission and discharge contributes to continuity of information and care.