Samenvatting

The research in this thesis emphasized that good transitional care adopts a holistic perspective, and is person-centered and developmentally appropriate. To make this possible, several practical recommendations have been formulated, but actual implementation into clinical practice lags behind due to the lack of a supportive context at the wider organizational and health care system levels. The time has come to look beyond the outpatient clinic and create a sense of urgency among health care managers, policy makers and health insurers. This requires consensus on the essential elements of transitional care and on the need for nationwide implementation. More evidence on working elements in transitional care is therefore needed, combined with insights into the financial and organizational resources that are needed to implement recommendations. This thesis has developed a comprehensive evaluation framework and showed some improved outcomes of transitional care efforts. However, results also confirmed that evaluating good transitional care is a complex matter, as it remains unclear what suitable outcome measures for transitional care are. The results obtained in combination with existing knowledge have taught us that we should critically reconsider whether it is realistic to expect significant outcomes on certain outcome measures, and shift our focus in transitional care evaluations. Moreover, attention should go out to longer follow-up periods, larger sample sizes, and long-term socioeconomic benefits of transitional care investments.