Improving transmural collaboration between hospital and home setting to promote continuity of care for patients with advanced cancer and their informal caregivers

To avoid the often abrupt transition between treatment in hospital and support at home for patients with advanced cancer and informal caregivers, oncological treatment on the one hand and support for palliative care needs on the other should gradually merge into each other. An integrated collaboration between
hospital services, primary care and specialised palliative care is
crucial in this respect. In co-creation with involved care providers, patients and
informal carers, agreements will be made on how transmural
cooperation can take place optimally and what role the existing
communication platform IRIS can have in this regard. These agreements will be
tested in a pilot project with 40 patients with advanced cancer in the
cancer in the Antwerp region for 12 months. During and after the trial
will be evaluated via focus groups and interviews to
to what extent the agreements have been respected, which barriers have
emerged for this and what impact the optimised transmural
collaboration had on continuity of care between hospital and home and
on the quality of life and satisfaction with care of patients and
informal carers. The final goal of this project is to arrive at a
blueprint on how transmural cooperation should take place
in order to ensure continuity of care between care settings and to meet the
palliative needs of patients with advanced cancer optimally.
palliative needs of patients with advanced cancer. This blueprint can subsequently be refined and rolled out in other regions.