Reengineering of a suburban post-acute ward into a community hospital

Abstract

Background: Chronic patients present highly complex conditions in which biomedical, psychosocial, and environmental factors are intricately intertwined. The population admitted to acute hospital wards is increasingly elderly and comorbid and often requires intermediate care. Objective: A decommissioned post-acute care ward within a district hospital will be rearranged into a 20bed community hospital. Integrated care through the biopsychosocial model will facilitate hospital discharges and prevent relapses: a reduction in admissions and length of stay in general hospitals for chronic patients is expected, along with improvements in patientrelated outcomes. Methods: A multi-professional board consisting of key stakeholders was convened to frame the organizational model and develop a digitally integrated chart. The International Classification of Functioning, Disability and Health (ICF) was chosen as the leading framework for patient assessment. The Individualized Care Plan (ICP) will be digitally implemented to tailor interventions to individual conditions. Families, caregivers, and general practitioners (GPs) will be actively involved, and periodic follow-ups will assess the progress of the plan