Transitional Care Innovation in Senior Citizens

Deliverables

Report on the process and outcome evaluation of a collaborative intervention model integrating home and nursing home care
Report on avoidable transitions in unplanned care

For D16 transitions after senior citizens seek unplanned care are critically explore Findings will be delivered through a report on avoidable transitions

Status report for dissemination and communication activities
Policy briefs of all ESR projects, in English and the Lead University language

Policy briefs of all ESR projects in English and the Lead University language

Report on cross-national integrated care lessons for optimising transitions

Report on crossnational integrated care lessons for optimising transitions

Report on transitional care effects of integrated nursing home care
Report of factors facilitating/hindering empowerment in transitional care

Report of factors facilitatinghindering empowerment in transitional care

Report on the implementation of integrated care initiatives for the optimisation of transitions from home to hospital
Report on the evaluation of the training program
Report on implementation barriers/facilitators for transitional LTC innovation
Report on implementation of INSPIRE

Report on the implementation and effects of the INSPIRE care model

Report on the feasibility and effects of CAPABLE-NL

D15 is a report on the feasibility and effects of CAPABLENL which results from the first evaluation of this care model

Report on integrated care effects for transitions from home to hospital
Report on organising and financing transitional care in European countries
Report on best practices for engaging senior citizens
Practice guideline for implementing senior citizen empowerment in transitional care
Report on approaches for transitional care involvement of senior citizens and informal caregivers

Assessment tool for evaluating organisation & financing of transitional LTC
Advertisement of ESR positions
Unplanned care triage protocols validated for senior citizens
Optimal transition support tools for a) senior citizens and informal care givers, and b) care professionals
Guideline on implementation strategies for transitional care
Online training materials for transitional care innovation
Online implementation toolbox
Protocol for INSPIRE care model
Protocol for the CAPABLE-NL model of care

For use in the South-Tirol setting, the existing CAPABLE intervention will be adjusted and tailored. D1.4 will result from this and contains the Protocol for the CAPABLE-NL model of care.

Tools for supporting (a) senior citizens and informal care givers, and (b) care professionals in care transition decisions

D1.1 Will deliver two practical tools. These tools will support (a) senior citizens and informal care givers, and (b) care professionals in care transition decisions. The tool are designed to impact on the quality of care.

Care pathway for the management of falls in nursing homes

D1.2 Is a care pathway for the management of falls in nursing homes. The care pathway will be designed with a view to preventing unnecessary transitions for nursing homes to hospitals.

Collaborative intervention model integrating home and nursing home care

Report on feasibility of a falls care pathway for avoiding transitions

D1.3 will be the result of the an evaluation of the care pathway developed for D1.2. D1.3 Is a report on the feasibility of the falls care pathway for avoiding transitions.

Publications

Transitional care decision-making through the eyes of older people and informal caregivers: An in-depth interview-based study

Author(s): Lotan Kraun, Theo van Achterberg, Ellen Vlaeyen, Bram Fret, Sarah Marie Briké, Moriah Ellen, Kristel De Vliegher
Published in: Health Expectations, 2023, ISSN 1369-7625
Publisher: Wiley
DOI: 10.1111/hex.13743

Exploring resident experiences of person-centred care at mealtimes in long-term residential care: a rapid ethnography

Author(s): Megan Davies, Franziska Zúñiga, Hilde Verbeek & Sandra Staudacher
Published in: BMC Geriatrics, Issue 22, 2022, ISSN 1471-2318
Publisher: BioMed Central
DOI: 10.1186/s12877-022-03657-5

Stakeholders’ experiences and perception on transitional care initiatives within an integrated care project in Belgium: a qualitative interview study

Author(s): Merel Leithaus, Amal Fakha, Johan Flamaing, Hilde Verbeek, Mieke Deschodt, Gijs van Pottelbergh, Geert Goderis
Published in: BMC Geriatrics, 2023, ISSN 1471-2318
Publisher: BioMed Central
DOI: 10.1186/s12877-023-03746-z

Toward a Partnership in the Transition from Home to a Nursing Home: The TRANSCIT Model

Author(s): Lindsay Groenvynck, Bram de Boer, Jan P.H. Hamers, Theo van Achterberg, Erik van Rossum, Hilde Verbeek
Published in: Journal of the American Medical Directors Association, 2020, ISSN 1525-8610
Publisher: Lippincott Williams & Wilkins Ltd.
DOI: 10.1016/j.jamda.2020.09.041

Changes in the use and uptake of a national out-of-hours telephone triage service by younger and older patients seeking non-urgent unplanned care surrounding the COVID-19 pandemic in Flanders (Belgium)

Author(s): Farah Islam, Koen Milisen, Marc Gellens, Joël Enckels, Ewa Kocot, Christoph Sowada, Marc Sabbe
Published in: Acta Clinica Belgica, International Journal of Clinical and Laboratory Medicine, 2022, ISSN 2295-3337
Publisher: Taylor & Francis
DOI: 10.1080/17843286.2022.2068296

Exploring Interrelations Between Person-Centered Care and Quality of Life Following a Transition Into Long-Term Residential Care: A Meta-Ethnography

Author(s): Megan Davies, Franziska Zúñiga, Hilde Verbeek, Michael Simon, Sandra Staudacher
Published in: The Gerontologist, 2022, ISSN 0016-9013
Publisher: Gerontological Society of America
DOI: 10.1093/geront/gnac027

Protocol for a mixed methods feasibility and implementation study of a community-based integrated care model for home-dwelling older adults: The INSPIRE project

Author(s): Olivia Yip, Maria Jose Mendieta, Leah L. Zullig, Andreas Zeller, Sabina De Geest, Mieke Deschodt, Flaka Siqeca, Franziska Zúñiga, Matthias Briel, Matthias Schwenkglenks, Carlos Quinto, Suzanne Dhaini
Published in: PLoS ONE, Issue 17, 2022, ISSN 1932-6203
Publisher: Public Library of Science
DOI: 10.1371/journal.pone.0278767

Strategies for engaging older adults and informal caregivers in health policy development: A scoping review

Author(s): Opeyemi Rashidat Kolade, Joshua Porat-Dahlerbruch, Rustem Makhmutov, Theo van Achterberg & Moriah Esther Ellen
Published in: Health Research Policy and Systems, 2024, ISSN 1478-4505
Publisher: BioMed Central
DOI: 10.1186/s12961-024-01107-9

Key Care Provision Aspects That Affect Care Transition in the Long-Term Care Systems: Preliminary Review Findings

Author(s): Estera Wieczorek, Ewa Kocot, Silvia Evers, Christoph Sowada, Milena Pavlova
Published in: International Journal of Environmental Research and Public Health, 2022, ISSN 1660-4601
Publisher: MDPI
DOI: 10.3390/ijerph19116402

A myriad of factors influencing the implementation of transitional care innovations: a scoping review

Author(s): Fakha, Amal ; Groenvynck, Lindsay ; de Boer, Bram ; van Achterberg, Theo ; Hamers, Jan ; Verbeek, Hilde
Published in: Implementation Science, Issue Vol. 16; iss. 1, 2021, ISSN 1748-5908
Publisher: BioMed Central
DOI: 10.1186/s13012-021-01087-2

Strategies for engaging senior citizens and their informal caregivers in health policy development: a scoping review protocol

Author(s): Opeyemi Kolade, Joshua Porat-Dahlerbruch, Theo van Achterberg, Moriah Ellen
Published in: BMJ Open, 2022, ISSN 2044-6055
Publisher: BMJ Publishing Group
DOI: 10.1136/bmjopen-2022-064505

Do financial aspects affect care transitions in long-term care systems? A systematic review

Author(s): Estera Wieczorek, Ewa Kocot, Silvia Evers, Christoph Sowada & Milena Pavlova
Published in: Archives of Public Health, Issue 80, 90, 2022, ISSN 2049-3258
Publisher: Springer
DOI: 10.1186/s13690-022-00829-y

Factors associated with health-related quality of life among home-dwelling older adults aged 75 or older in Switzerland: a cross-sectional study.

Author(s): Flaka Siqeca, Olivia Yip, Maria José Mendieta, Matthias Schwenkglenks, Andreas Zeller, Sabina De Geest, Franziska Zúñiga, Samuel Stenz, Matthias Briel, Carlos Quinto, Eva Blozik, Mieke Deschodt, Katrina Obas & Suzanne Dhaini
Published in: Health and Quality of Life Outcomes, Issue 20, 2022, ISSN 1477-7525
Publisher: BioMed Central
DOI: 10.1186/s12955-022-02080-z

The perspectives of older people living with dementia regarding a possible move to a nursing home

Author(s): Groenvynck L, Khemai C, de Boer B, Beaulen A, Hamers JPH, van Achterberg T, van Rossum E, Meijers JMM, Verbeek H.
Published in: Aging Ment Health, Issue 27, 2023, Page(s) 2377-2385, ISSN 1360-7863
Publisher: Carfax Publishers
DOI: 10.1080/13607863.2023.2203693

Fostering the implementation of transitional care innovations for older persons: prioritizing the influencing key factors using a modified Delphi technique

Author(s): Amal Fakha, Bram de Boer, Theo van Achterberg, Jan Hamers & Hilde Verbeek
Published in: BMC Geriatrics, Issue 22, 2022, ISSN 1471-2318
Publisher: BioMed Central
DOI: 10.1186/s12877-021-02672-2

Core components and impact of nurse-led integrated care models for home-dwelling older people: A systematic review and meta-analysis

Author(s): Mieke Deschodt, Gwen Laurent, Lonne Cornelissen, Olivia Yip, Franziska Zúñiga, Kris Denhaerynck, Matthias Briel, Azra Karabegovic, Sabina De Geest
Published in: International Journal of Nursing Studies, Issue 105, 2020, Page(s) 103552, ISSN 0020-7489
Publisher: Pergamon Press Ltd.
DOI: 10.1016/j.ijnurstu.2020.103552

Integrated Care Components in Transitional Care Models from Hospital to Home for Frail Older Adults: A Systematic Review

Author(s): Merel Leithaus, Audrey Beaulen, Erica de Vries, Geert Goderis, Johan Flamaing, Hilde Verbeek, Mieke Deschodt
Published in: International Journal of Integrated Care, 2022, ISSN 1568-4156
Publisher: Igitur, Utrecht Publishing and Archiving Services
DOI: 10.5334/ijic.6447

Implementing Four Transitional Care Interventions for Older Adults: A Retrospective Collective Case Study

Author(s): Amal Fakha, Merel Leithaus, Bram de Boer, Theo van Achterberg, Jan P Hamers, Hilde Verbeek
Published in: The Gerontologist, Issue 63, 2023, Page(s) 451–466, ISSN 1758-5341
Publisher: Oxford Journals
DOI: 10.1093/geront/gnac128

Systematic development of a set of implementation strategies for transitional care innovations in long-term care

Author(s): Amal Fakha, Bram de Boer, Jan. P. Hamers, Hilde Verbeek & Theo van Achterberg
Published in: Implementation Science Communications, 2023, ISSN 2662-2211
Publisher: Springer
DOI: 10.1186/s43058-023-00487-3

Exploring the Support and Involvement of Family Caregivers for Reablement Programs: A Qualitative Study

Author(s): Mouchaers I, Metzelthin S, van Haastregt J, Vlaeyen E, Goderis G, Verbeek H
Published in: Journal of Multidisciplinary Healthcare, 2023, ISSN 1178-2390
Publisher: Dove Medical Press Ltd
DOI: 10.2147/jmdh.s424147

Older peoples' and informal caregivers' experiences, views, and needs in transitional care decision-making: a systematic review

Author(s): Lotan Kraun, Kristel De Vliegher, Marie Vandamme, Emilie Holtzheimer, Moriah Ellen, Theo van Achterberg
Published in: International Journal of Nursing Studies, Issue 134, 2022, ISSN 0020-7489
Publisher: Pergamon Press Ltd.
DOI: 10.1016/j.ijnurstu.2022.104303

Development of a tool for assessing the performance of long-term care systems in relation to care transition: Transitional Care Assessment Tool in Long-Term Care (TCAT-LTC)

Author(s): Estera Wieczorek, Ewa Kocot, Silvia Evers, Christoph Sowada & Milena Pavlova
Published in: BMC Geriatrics, 2023, ISSN 1471-2318
Publisher: BioMed Central
DOI: 10.1186/s12877-023-04467-z

The paradoxes experienced by informal caregivers of people with dementia during the transition from home to a nursing home

Author(s): Lindsay Groenvynck, Bram de Boer, Audrey Beaulen, Erica de Vries, Jan P H Hamers, Theo van Achterberg, Erik van Rossum, Chandni Khemai, Judith M M Meijers, Hilde Verbeek
Published in: Age and Ageing, Issue 51, 2022, ISSN 1468-2834
Publisher: Oxford University Press
DOI: 10.1093/ageing/afab241

Interventions to Improve the Transition From Home to a Nursing Home: A Scoping Review

Author(s): Lindsay Groenvynck, Amal Fakha, Bram de Boer, Jan P H Hamers, Theo van Achterberg, Erik van Rossum, Hilde Verbeek
Published in: The Gerontologist, 2021, ISSN 0016-9013
Publisher: Gerontological Society of America
DOI: 10.1093/geront/gnab036

Identifying key items to be addressed by non-clinical operators to manage out-of-hours telephone triage services for older adults seeking non-urgent unplanned care in Belgium: an e-Delphi study

Author(s): Farah Islam, Pieter Heeren, Kelu Yang, Koen Milisen & Marc Sabbe
Published in: BMC Health Services Research, 2024, ISSN 1472-6963
Publisher: BioMed Central
DOI: 10.1186/s12913-024-10657-1

Health and social care of home-dwelling frail older adults in Switzerland: a mixed methods study

Author(s): Olivia Yip, Suzanne Dhaini, Jan Esser, Flaka Siqeca, Maria Jose Mendieta, Evelyn Huber, Andreas Zeller, Sabina De Geest, Mieke Deschodt, Franziska Zúñiga, Leah L. Zullig, Heather A. King & the INSPIRE consortium
Published in: BMC Geriatrics, Issue 22, 2022, ISSN 1471-2318
Publisher: BioMed Central
DOI: 10.1186/s12877-022-03552-z

Consistency of decision support software-integrated telephone triage and associated factors: a systematic review

Author(s): Farah Islam, Marc Sabbe, Pieter Heeren, Koen Milisen
Published in: BMC Medical Informatics And Decision Making, Issue Vol. 21, 2021, ISSN 1472-6947
Publisher: BioMed Central
DOI: 10.1186/s12911-021-01472-3

A multi-level perspective on perceived unmet needs for home support in home-dwelling older adults in the Swiss context: a secondary data analysis of a population study

Author(s): Maria Jose Mendieta, Sabina M De Geest, Geert Goderis, Olivia Yip, Mieke Deschodt, Suzanne Dhaini & the INSPIRE Consortium
Published in: BMC Geriatrics, Issue 14712318, 2022, ISSN 1471-2318
Publisher: BioMed Central
DOI: 10.1186/s12877-022-03479-5

Avoidable care transitions: A consensus-based definition using a Delphi technique

Author(s): Rustem Makhmutov, Gabriele Meyer, Moriah E Ellen, Steffen Fleischer
Published in: Innovation in Aging, 2023, ISSN 2399-5300
Publisher: Oxford Academic
DOI: 10.1093/geroni/igad106

Interventions for the empowerment of older people and informal caregivers in transitional care decision-making: short report of a systematic review

Author(s): Lotan Kraun, Kristel De Vliegher, Moriah Ellen and Theo van Achterberg
Published in: BMC Geriatrics, Issue 23, 2023, ISSN 1471-2318
Publisher: BioMed Central
DOI: 10.1186/s12877-023-03813-5

The concept of disability and its causal mechanisms in older people over time from a theoretical perspective: a literature review

Author(s): Ines Mouchaers, Hilde Verbeek, Gertrudis I. J. M. Kempen, Jolanda C. M. van Haastregt, Ellen Vlaeyen, Geert Goderis & Silke F. Metzelthin
Published in: European Journal of Ageing, 2022, ISSN 1613-9380
Publisher: Springer
DOI: 10.1007/s10433-021-00668-w

Development and content of a community-based reablement programme (I-MANAGE): a co-creation study

Author(s): Ines Mouchaers, Hilde Verbeek, Gertrudis I J M Kempen, Jolanda C M van Haastregt, Ellen Vlaeyen, Geert Goderis, Silke F Metzelthin
Published in: BMJ Open, 2023, ISSN 2044-6055
Publisher: BMJ Publishing Group
DOI: 10.1136/bmjopen-2022-070890

"""Reablement"" commeoutil thérapeutique pour offriraux personnes âgéesune viede qualité à domicile après une réadaptationgériatrique"

Author(s): Mouchaers Ines,Van Haastregt J.C.M.,Verbeek K.,Kempek G.I.J.M., Vlaeyen E.,Goderis G.,MetzhelthinS.F.
Published in: Revue Médicale de Bruxelles, Issue 42 - 4, 2021
Publisher: Revue Médicale de Bruxelles

Long-Term Care Staff Perceptions of Providing Care During the COVID-19 Pandemic in the United States and Switzerland: Balancing Protection and Social Isolation

Author(s): Freidus, A., Shenk, D., Davies, Megan, Wolf, C., Staudacher, S.
Published in: Caring on the Frontline during COVID-19: Contributions from Rapid Qualitative Research, 2022, Page(s) 159-78, ISBN 978-981-16-6486-1
Publisher: Palgrave Macmillan
DOI: 10.1007/978-981-16-6486-1_8

Policies and Politics: An Analysis of Public Policies Aimed at the Reorganisation of Healthcare Delivery During the COVID-19 Pandemic

Author(s): Lewis-Jackson, Sasha, Eleonora Iob, Valentina Giunchiglia, Jose Roberto Cabral, Maria Romeu-Labayen, Silvie Cooper, Rirhandzu Makamu, et al.
Published in: Caring on the Frontline during COVID-19, 2022, Page(s) 39-64, ISBN 978-981-16-6486-1
Publisher: Palgrave Macmillan
DOI: 10.1007/978-981-16-6486-1_3

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