[Transitional care from hospital to home: how to target the right population?]
Carole Michalski-MonneratMarie-Laure Jacquot-PegeotSylvie RochatMarie-Christine SchmidStéphanie Maillat RothNicolas ChevreyYaëlle ToledanoJean Gabriel JeannotJacques DonzéDenise Bryant-LukosiusCédric MabirePublished in: Revue medicale suisse (2023)
When patients are discharged from the hospital and return home, they are at risk of adverse events if the continuity of care is broken. So far, the evidence for transitional care models to reduce readmission rates has focused mainly on patients with a single condition. Based on this observation, we identified the population that may benefit the most from the development of a new transitional care model, as part of the INSTEAD project, by consensus between patients and professionals in hospitals and the community. To ensure continuity of care, it is necessary to consider the patients' perception, their understanding of the care plan and changes impacting the home care plan. Interprofessional collaboration is essential to achieve this.