Towards a better understanding of goal oriented care by means of co-creating an interprofessional training program with experts by experience
Authors: Haverals Reini , Wauters Annet , Vanneste Lotte , Boeckxstaens Pauline 
Published: January 2024

The literature defines transitional care as the coordination and continuity of care during the transition from one health care setting to another or to home. Referred to as transition of care, between health care professionals and settings, as their condition and care needs change during the course of a chronic illness, acute illness or acute admission. In this scenario, the transition of care from hospital to home carries a number of risks of adverse events and poor care continuity. Therefore, daily technologies such as wearables and smart devices can support the improvement of interventions as they can collect up-to-date daily data from patients, helping to gain an in depth understanding of the real situation and their healthcare needs, improving the transition care process.

The aim of this research, integrated in VITALISE Project (H2020.GA101007990), is to identify and explore the needs, barriers and challenges of transitional care by involving different stakeholders in different participating countries. In Spain 3 patients, 2 carers and 7 health professionals participated in co-creation sessions with a person-centred approach addressing the topic of using ICT tools to gather information/data to support the transitional care process (hospital discharge process and recovery at home) and to collect information on current practices in transitional care processes (from hospital to home).

Two sessions with patients, carers and with professionals, aimed to understand the different perspectives on each profile, enriching the comments and contributions. Two facilitators with experience guiding accessible co-creation sessions ensured each participant had a space for participation. The sessions were distributed in four blocks: 1) understanding the current practice in transitional care; 2) experience in the use of smart devices and digital tools; 3) understanding the barriers, difficulties and challenges in using digital tools in this process and 4) what the ideal role of technology would be.

As a finding, during the patients and carers session participants highlighted that there should be a protocol for the transition process but that it is currently not established and it all depends on how ""fortunate"" you are. They appreciate the advantages given by the health system in their respective country, but they do not agree with the organisational set-up or with some specific actions. Regarding technology, they mostly accept technology in transition processes and believe that it can bring many benefits helping to improve (as long as it is not used to replace human care). On the other hand, professionals use technology in their work on a daily basis and have a very broad view of its impact on people's experiences and its acceptability. Finally, beyond the benefits for the user, professionals take advantage of these technologies to improve individual care and systematise the collection of information. Overall, the inclusion of digital technologies is accepted in integrated and transitional care processes, when adapted to the users and not the other way around. These findings are key for the preparations of the small-scale studies phase “Digital Biomarkers for Supporting Transitional Care Decisions: Protocol for a Transnational Feasibility Study” [JMIR Res Protoc.2022Jan19;11(1):e34573.doi:10.2196/34573].