Home health care (HHC) organizations as well as hospitals encounter information-tracking problems regarding their patients. When a patient is admitted to the hospital, it is not always possible/easy to find out if this person already had HHC and if so, by which organization it was provided. HHC organizations also not always know to which hospital a person is admitted. At discharge, although discharge documents exist, HHC organizations not always receive the necessary information. However, sharing information between the different care-partners involved is important, among others for the continuity of care. Hospitals will gain better insight in the provided home care before admission, and HHC organizations will get a more complete and direct insight in the course of care at the hospital. In doing so, they are better prepared to provide the necessary care for the patient admitted to the hospital or returning at home. Discussion with the partners involved in the IBBT-Trans-eCare project resulted in tracking the current problems, defining goals and presenting a solution to meet the defined problems.
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