TULIP – TransmUraL Integrated allied healthcare Pathway

The TULIP project is a four-year project, launched in 2023, that focuses on the transition from hospital to home for patients with complex care needs after hospitalization. Patients in the transition phase from hospital to home are at high risk of incomplete recovery due to a lack of continuity of care and interprofessional coordination. The allied healthcare needs after discharge are often insufficiently assessed, and coordination and collaboration in primary care are often lacking. This project develops an integrated transmural allied health care pathway for patients with allied healthcare needs after a complex hospital admission.

Who?

We focus on patients who require multidisciplinary allied healthcare during and after hospitalization. We are starting in two clinical departments at Amsterdam UMC: internal medicine and trauma surgery. This may be expanded to other departments in the future.

How?

We have developed a transmural allied healthcare pathway consisting of the following steps:

1. Early identification of patients who need allied healthcare aftercare hospital discharge
2. Appointing a coordinator to guide the patient through the transition from hospital to home
3. Involving patients, familes and informal carers in the transition from hospital to home
4. A uniform and digital handover from hospital to geriatric rehabilitation services and primary care
5. Referral within specialized allied healthcare networks in the region
6. A telephone follow-up within 6 weeks after discharge

Performed by

Funded by