Samenvatting

The current healthcare delivery system is under pressure. With an aging population and changing lifestyles, the incidence and prevalence of chronic diseases have grown steadily worldwide. It is presumed that people with multiple chronic diseases account for a very large proportion of healthcare utilization and costs. Nearly twenty percent of patients who have been discharged from the hospital are readmitted within 30 days. The reason for unplanned hospital readmission is often complex and caused by multiple health issues. The overall aim of this thesis is to improve patient-centered care for acutely admitted chronically ill patients in the transition from hospital to home to prevent unplanned hospital readmission. To increase insight into organizational, behavioral, and social factors associated with unplanned hospital readmission qualitative and quantitative studies were conducted. The results provide a description of how patients perceive transitions of care, how healthcare professionals perceive interprofessional communication and collaboration, and interventions to improve transitions of care from hospital to home. Finally, recommendations for healthcare professionals were written to suggest how to organize transitions of care for chronically ill patients at risk for unplanned hospital readmissions.