The aim of my research line is to develop and implement person-centered transitional care models for older persons. I see patient participation and collaboration with scientists from other disciplines (e.g. medicine, basic science, communication, technology and psychology) as the key to accomplish this goal. Three subthemes are contributing to accomplish the main aim.

In the first subtheme ‘Epidemiology of Health Outcomes’, I perform cohort studies on the mechanisms behind negative health outcomes in older persons during and after hospitalization such as hospitalization-associated disability, readmission, mortality and quality of life. For example in a new prospective cohort study, the hospital-ADL study we are unraveling the mechanism behind hospitalization-associated disability, a major driver of loss of independence in older persons. In this study biological, physical, psychological, medical and organizational factors present during hospitalization and three-months post-discharge are studied.

These cohort study outcomes are used in the second research theme ‘Development and Testing of Transitional Care Models’ in which my group performs systematic reviews and complex intervention trials on how professionals in hospitals, nursing homes and primary care can work together to improve health outcomes and redesign parts of the health care system. An example is the Transitional Care Bridge RCT, in which vulnerable older persons are guided from hospital admission until six-months post-discharge and led to a significant reduction in mortality, with good quality of life outcomes and no additional costs.

The third research theme ‘Sustainable Transitional Care in Different Health Care Systems’ focuses on up scaling interventions that have proven to be effective and how to built sustainable transitional care in different health care systems. In this subtheme, I work together with the department of Nursing and Global Health from Duke University on an international network with high-middle- and low-income countries that study how to deliver transitional care in different health care systems.