出版社：Utrecht University, Maastricht University, Groningen University
摘要：Upon the Integrated Care Exchange program initiated between Oldham CCG and Catalan healthcare providers (Hospital Clinic, CHV, CAPSE and CASAP) and co-organised by AQuA and IFIC in 2014-2015, we do aim to continue the learning exchange around a central topic: Transitional Care. We propose a double session. The first one will address different interventions in Transitional Care to be compared following a similar presentation pattern that will allow to identify the lessons learns in three key aspects: value sources, SWOT analysis, scale-up and sustainability in the long run. Interventions selected: 1. Virtual integration model: hospital and primary care in Vic 2. Emergency care as key place for transition management: geriatric assessment, situational diagnostic and community resources management The second session will cover the patient perspective in the transition within and among health institutions. Patient experience is a driver for healthcare improvement in transitional care. Interventions selected: 1. Patient participatioin in integrated care (Oldham CCG) 2. Person-centered prescription (Hospital Santa Creu) 3. The patient journey of diabetic patients (CASAP) We have already secured presentations from: Hospital Santa Creu (Vic, Spain), CASAP (Castelldefels, Spain), Oldham CCG (Oldham, UK). We are open to accomodate presentations for third parties that fit the topic.
关键词：transitional Care ; patient experience ; participation ; continuum of care
