SPX Colloquium – Communication Sessions A3
At the SPX International Colloquium 2025, we are pleased to present the communication panel:
Adressing the challenge of transitions within continuum of care.
Let’s focus specifically on the patient experience in the continuum of care, particularly the critical phase of transitions.
This session will showcase how four institutions from Belgium, France, Spain and Switzerland have incorporated the patient perspective into their practices and projects.
This communication session will be chaired by xxx (To Be Announced Soon).
The following communications will be presented during this session:
1
Enhancing Care Continuity for Vulnerable CKD Patients through Shared Decision-Making: Long-Term Impact of Interprofessional Discharge Workshop with Patient Experts
Perrine Thiry, Katja Swinnen
Health Innovation UCLL (Belgium)
Language: English
Project’s description:
Vulnerable care recipients with chronic kidney disease (CKD) benefit greatly from good continuity of care, especially during the transition from hospital to primary care. Gaps in this transition often result in preventable complications and readmissions. These issues are frequently related to unclear responsibilities, insufficient patient education, lack of interprofessional coordination, and poor information exchange. Vulnerable patients, particularly those with limited health literacy or social support, are most at risk in such fragmented discharge processes. There is a growing need to engage patients and informal caregivers, strengthen interprofessional coordination, and promote shared clinical responsibility to ensure safe and continuous care transitions.
This study aimed to implement and evaluate an interprofessional discharge intervention to improve care continuity for vulnerable CKD patients. Central to this intervention were shared decision-making, clear role allocation, and patient empowerment. The research also examined the long-term effects of the intervention on healthcare providers’ attitudes and practices, particularly in relation to discharge responsibilities and collaboration.
A mixed-methods design was used. Based on literature review and qualitative interviews with patients, caregivers, and professionals from both primary and specialized care, core needs were identified. These insights informed the development of a tailored intervention, including a discharge checklist and interprofessional workshops. Three workshops were conducted with 21 healthcare professionals and patient experts on the nephrology ward. A pre- and immediate post-assessment evaluated changes in awareness and collaboration. A follow-up assessment six months later (response rate: 52%) provided insights into long-term impact.
The workshops significantly improved role clarity, awareness of discharge responsibilities, and interprofessional communication. Healthcare providers reported increased understanding of each other’s roles and tasks in the discharge process. Six months later, most improvements were sustained: participants continued to recognize discharge as a shared task, knew who to contact with questions, and retained insight into factors influencing discharge decisions.
While most improvements were sustained after six months, certain areas—such as systematic involvement of patients in discharge planning and communication with primary care providers—still offer room for further reinforcement. A majority of respondents (69%) reported continued engagement of patients in the discharge process, indicating a solid foundation that can be strengthened through ongoing reflection and practice. Intra-team communication remained strong, and growing awareness of the importance of collaboration with primary care was evident, though not yet fully integrated into routine workflows. The discharge checklist was widely appreciated as a practical and clarifying tool, and its structured implementation is the next logical step. These findings underscore the importance of repeating the interprofessional workshops at regular intervals to sustain, embed behavioral change, and further consolidate shared responsibility in discharge planning. The workshop format piloted on the nephrology ward was subsequently adapted and implemented on three additional units—geriatrics, intensive burn care, and pediatric orthopaedics. On all these wards, immediate post-workshop assessments demonstrated increased awareness of roles and responsibilities. Moreover, all teams explicitly acknowledged the added value of involving patients and informal caregivers in the discharge process and expressed commitment to further embed this perspective into their practice.
This study shows that co-creating discharge interventions with healthcare professionals and patient experts leads to improved continuity of care and sustainable change in discharge practices. Interprofessional workshops proved effective in fostering shared clinical responsibility, role awareness, and collaboration. The long-term follow-up demonstrated that most attitudinal and behavioral changes were maintained. The successful implementation across other hospital departments confirms the transferability and perceived value of this approach. Nonetheless, systematic communication with primary care and consistent patient engagement remain key areas for further improvement. Embedding the discharge checklist and reinforcing shared decision-making practices will be crucial in scaling this intervention sustainably.
2
Patient Experience: Integrating Quality of Life and Empowerment into Home Care Services
Sélim Coll, Alessandra Canuto
Institution genevoise de maintien à domicile (IMAD) (Swizterland)
Language: French
Project’s description:
In the 20th century, rising living standards reshaped our understanding of health—from the mere absence of illness to a broader concept of well-being, where individuals’ perceptions of their own health are central. This shift highlights two key concepts in patient care: quality of life and empowerment. Quality of life reflects how individuals view their place in life, shaped by cultural context, values, goals, and concerns. Empowerment refers to a person’s ability to understand, choose, and act independently in managing their health.
The Geneva Institution for Home Care and Assistance (IMAD), through its Community Health and Living department, is integrating these concepts into its “360° Evaluation” program. The aim is to offer more personalized individual or community-based activities, grounded in a comprehensive understanding of each patient’s needs. Each patient will undergo a full assessment using the interRAI Community Health Assessment tool, covering clinical, functional, psychological, and social aspects. Two standardized questionnaires—the WHOQOL-BREF and the Boston University Empowerment Scale—will be administered at intake and annually or as needed.
By analyzing this data, IMAD will better identify patient needs and evaluate how well current services align with them. This will help refine support offerings to improve quality of life and foster greater patient autonomy. In turn, care relationships will become more collaborative. In the medium term, this approach will benefit Geneva’s home care system by promoting a more individualized, participatory, and sustainable model of healthcare.
3
Redefining the Hospital Discharge Process for Frail Older Adults: A Patient-Centred Care Model for Home Transitions
Maite Franco Romero
Parc Sanitari Pere Virgili (Spain)
Language: English
Project’s description:
Hospital discharge is a pivotal moment in the care trajectory of frail older adults. It often signifies a shift from an environment of high medical support to one where professional presence is limited or intermittent. In this transition, many patients and their caregivers report feelings of uncertainty, lack of preparedness, and fragmented communication between care levels. With population ageing and a rise in chronic conditions, there is an urgent need to reimagine discharge planning from the lens of patient experience.
This project aimed to redesign the hospital discharge process for frail older adults transitioning to home, integrating the voices of patients, caregivers, and professionals. The goal was to develop a person-centred clinical pathway that ensures continuity of care, shared decision-making, and tailored therapeutic education that supports patient autonomy and well-being.
A mixed-methods study was conducted using a participatory design approach. The process was structured around four key phases inspired by design thinking:
Empathise: Semi-structured interviews were conducted with patients, informal caregivers, and professionals from both hospital and primary care, to explore lived experiences, fears, expectations, and communication needs surrounding the discharge process.
Define: Quantitative institutional data were analysed, including the number of discharges, use of the PREALT document, and patient risk levels (Adjusted Morbidity Groups – GMA). Focus groups identified gaps in the current discharge workflow and mapped priority needs.
Ideate and Prototype: Based on the findings, a modular and adaptable clinical pathway was co-designed. Key components included early frailty screening, structured communication across care levels, standardised discharge planning, and personalised post-discharge follow-up.
A central element of the prototype was the development of a therapeutic education strategy adapted to the patient’s functional, cognitive and social profile. Educational interventions were designed to respond to the patient’s level of health literacy (assessed with tools such as REALM) and their emotional readiness, ensuring that the information was understandable, relevant, and empowering.
The process highlighted multiple areas that significantly impact the patient experience:
Uncertainty at discharge: Patients often felt unprepared and emotionally overwhelmed upon returning home, particularly in the absence of supportive care networks.
Educational needs unmet: Many patients and caregivers reported receiving verbal instructions that were either too complex, too general, or poorly timed.
Limited use of planning tools: The PREALT document was inconsistently applied, even among patients at higher risk.
Communication breakdowns: Professionals noted a lack of coordination between levels of care, resulting in a sense of disconnection and lack of follow-up.
The new clinical pathway addressed these issues by proposing a personalised and structured discharge process that incorporates patient education as a core component. Therapeutic education was delivered by nurses trained to adapt content to the patient’s comprehension level, emotional state, and capacity for self-care. This approach aimed to reduce anxiety, reinforce autonomy, and foster safer transitions.
In addition, the pathway included the definition of experience and outcome indicators (PREMs and PROMs) to guide future evaluation and continuous improvement.
A safe and positive transition to home for frail older adults requires more than medical stability. It involves recognising the individual’s need for understandable, relevant information and emotional support. Therapeutic education—delivered at the right moment, in the right way—is essential for building confidence, promoting self-care, and enhancing the overall patient experience. This project offers a replicable model for rethinking discharge as a human-centred, educative and coordinated process.
4
L’hôtel hospitalier à l’hôpital FOCH
Aléna Sorret, Valérie Loisel
Hôpital Foch (France)
Language: French
Project’s description:
L’hôpital FOCH a mis en place l’hôtel hospitalier (Hébergement Temporaire Non Médicalisé) pour accueillir ses patients.
L’hébergement proposé est “mixte”, s’appuyant à la fois sur des hôtels de tourisme conventionnés, une résidence associative et un service hôtelier intra hospitalier.
La gestion de ces nuitées non médicalisées est réalisée via la plateforme digitale My Hospitel, testée en interne par des utilisateurs et des professionnels au sein du Living Lab de l’hôpital. Une démarche complète, qui permet d’améliorer l’expérience des patients éligibles sans surcharge pour les professionnels hospitaliers, vecteur d’une efficience hospitalière améliorée.
Looking for another panel about Patient Experience?
For the full overview of sessions, topics and speakers, we invite you to explore the complete SPX International Colloquium 2025 programme. Discover the diversity of perspectives and initiatives that will be shared in Luxembourg from 6 to 8 October.
