Table 1 Description of actions

Objective

To reduce the burden on hospitals during the first wave of COVID-19 and therefore to provide an immediate solution during the crisis

To create close networks of local health care professionals at neighborhood level in order to provide integrated care for patients and to detect vulnerable groups early on. The action aims to strengthen and structure primary care and improve cooperation between primary care, secondary care and tertiary care

To support the discharge process from the hospital by providing information on medication to the community pharmacist therefore allowing pharmacists to provide medication reconciliation to discharged patients

To improve care for heart failure patients by implementing four guideline-recommended disease management interventions

Transitional care focus

To provide support during two care transitions:

1) transition from hospital to intermediate care center and,

2) transition from intermediate care center to the community

To prevent unnecessary care transitions from the community setting to the hospital by connecting the neighborhood and providing early integrated care for vulnerable patients including coordination of care

To facilitate the information transfer on medications during the care transition from hospital to the community pharmacist

To avoid unnecessary care transitions to the hospital and improve necessary transitions from the hospital to the community

Patient target group

Vulnerable patients who were medically able to leave the hospital and who (often for social reasons) couldn’t go home yet - both patients with a COVID-19 infection or without an infection

Each neighborhood team decided on their own target population, however the focus was especially on the vulnerable or multimorbid population

All patients discharged from participating hospital departments

Heart failure patients or patients with a risk for heart failure living in the community or being admitted at the cardiology ward

Main HCPs involved

Coordinating pharmacist, community pharmacist, home care nurse, head nurse, social worker, GP, specialist, psychologist

Local health care professionals from the same neighborhood including: GP, pharmacist, physiotherapist, home care nurse, psychologist, tabaccologist, dietician, social worker

Nurse at discharge and community pharmacist

Heart failure educator, GP, heart failure nurse at the hospital ward, cardiologist, home pharmacist

Key components

• Coordination of medical, pharmaceutical and social care to arrange a seamless transition between the hospital and the intermediate care center and the intermediate care center and the home setting

• The patients GP, pharmacist and home nurse were contacted and informed and if necessary a follow-up appointment was scheduled for the patient

Each neighborhood team developed specific aims and approaches for their patients that resulted in diverse projects such as:

• group sessions to provide information on different topics (e.g. loneliness, healthy habits, positive health)

• coaching sessions within the neighborhood such as walking moments or smoking cessation campaign for COPD patients

• implementation of disease programs

• The patient receives an envelope from the nurse at discharge containing necessary documents to perform a medication reconciliation: medication scheme from the hospital, medication prescriptions at discharge and a registration form. The envelope is addressed to the community pharmacist.

• To keep track of conducted medication reconciliations, community pharmacists are requested to scan the code of the envelope and to fill in a registration form

The following four interventions were implemented:

1. To improve the first-line diagnostics by reimbursing the natriuretic peptides test (NT-proBNP) for GP’s in Leuven which allows diagnosing heart failure

2. To implement automated diagnostic and qualitative audits for heart failure in primary care settings that help to safeguard high quality care for patients

3. To provide a heart failure education session that focus on self-care management for high-risk patients. GP’s or HCPs at the hospital can contact trained nurses to provide an education session to their patients

4. To improve the discharge moment for heart failure patients at the hospital by implementing a structured discharge protocol including: a checklist for high risk patients, telephone contact with the patient GP to plan follow-up appointment and heart failure education session 14 days after discharge

Synergies

• Siilo application: a secure medical messenger for HCPs

• Medication envelope (Action 3)

• Siilo application

• NexusHealthPro software: expending software access to several health care professional groups including physiotherapists, nurses, pharmacists, dentists and midwives. The software allows to consult hospital files of patients

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• Medication envelope (Action 3)

Implementation status

The action was implemented during the first wave of COVID to provide an immediate solution during the crisis and was stopped afterwards

8 neighborhood teams are running in the region of ZZL and each team roughly covers a population of 5000–8000 inhabitants

The action is implemented within various departments of three hospital in the region/close to the region of ZZL

The action is implemented at various hospitals (cardiology department) and at the community (homecare and primary care)

Context information

Coordinating pharmacist organized the medication follow-up from admission until discharge. The role of the coordinating pharmacist was tested first in Belgium within the intermediate care center

The neighborhood teams were structured based on ‘natural’ networks in the community. A division of 24 small neighborhoods of 4000 inhabitants exist in Leuven and has been used to start the networking of neighborhoods within ZZL [21]

The action fills a current gap to digitally share information on medications at discharge

The four interventions have been tested previously in the Belgium setting [22]