Short summary

Systematic knowledge about the transition of patients from hospital to short-term rehabilitation before return to home or nursing home is sparse, and knowledge about the organizational structures and the organization of the daily work is limited. In this study, we aim to explore and map the challenges related to the transition of patients from hospital to short-term rehabilitation in relation to (i) medication management (ii) responsibility of the medical treatment and (iii) communication.

Rationale

Post-admission some patients are not always well enough to return to their home. These patients require continued care and extended recovery time, and therefore they are offered a short-term rehabilitation stay. During the last years, the number of hospital beds have decreased, while more and more patients are discharged to short-term rehabilitation stays. As a result, the municipalities have to handle a growing number of more complex citizens who are frail after hospital admission.

After a preliminary meeting with relevant stakeholders and a visit at the short-term rehabilitation facility "Lysningen" in Odense Municipality, we found consensus to explore and map the challenges related to the transition of patients from hospital to short-term rehabilitation in relation to (i) medication management (ii) responsibility of the medical treatment and (iii) communication in the transition of hospital and short-term rehabilitation.

Hence, with this study, we aim to map the challenges that occurs when patients are discharged from hospital to short-term rehabilitation.

Description of the cohort

The cohort include all patients admitted to either a medical or a surgical department at Odense University Hospital and discharged to the short-term rehabilitation stay at the short-term rehabilitation facility "Lysningen" in Odense Municipality.

Data and biological material

The study is an observational study with descriptive data. Demographics, medical and residential information, and data about communication, telephone calls etc. will be registered.

Collaborating researchers and departments

The short-term rehabilitation center "Lysningen" in Odense

• Kristine Kolberg

Hospital Pharmacy Funen, Odense University Hospital

• MSc Pharm, ph.d. DMSc Anton Pottegård
• MSc Pharm, ph.d. Carina Lundby

Acute Admission Ward, Odense University Hospital

• MD, DMSc Annmarie Lassen