If you are a home care provider dealing with fragmented patient hand-overs from hospitals — this project developed a toolbox and training modules that improve communication and care planning. This ensures patients are managed correctly at home, reducing crisis-driven emergency calls.
Standardized Transitional Care Program to Reduce Hospital Readmissions for Advanced Cancer Patients
Imagine a patient leaving a hospital for home care, but the hand-off is like a dropped call where critical info is lost. This project creates a clear playbook and training for doctors to ensure the transition is seamless. It's like a GPS for end-of-life care that keeps everyone on the same page to avoid unnecessary emergency trips back to the hospital.
What needed solving
Patients with advanced cancer often face fragmented care when moving from hospital to home, leading to poor quality of life and avoidable hospital readmissions.
What was built
A transitional care program including a blended training curriculum, an intervention manual, and a toolbox of algorithms for communication and care planning.
Who needs this
Who can put this to work
If you are a software company dealing with poor continuity of care data — this project developed a set of algorithms and instruments for difficult decisions and care planning. These can be integrated into digital tools to standardize how clinicians transfer patients between settings.
If you are a training center dealing with a lack of standardized palliative communication skills — this project developed a blended curriculum and train-the-trainer program. This allows for the rapid deployment of certified communication skills across different clinical settings.
Quick answers
What is the cost or price of implementing this program?
Based on available project data, no specific pricing or licensing costs for the program are mentioned; it is currently a research-funded initiative.
Can this be scaled to an industrial level?
The program is designed for scale, having already been adapted to the local contexts of 7 different European countries.
What is the IP or licensing status of the toolbox?
Based on available project data, the IP status is not specified, but the project has produced a toolbox and training materials for implementation.
How does this integrate with existing hospital workflows?
It integrates via a five-step process including patient identification, compassionate communication, and collaborative care planning between hospital and community settings.
What is the timeline for deployment?
The project runs from 2022-09-01 to 2027-08-31, with the current phase focusing on the design and preparation of a randomized controlled trial.
Who built it
The consortium is heavily academic, consisting of 7 universities and 1 research organization out of 10 partners. There are 0 industry partners and 0 SMEs, indicating the project is currently in a high-science validation phase rather than a commercialization phase. The geographic spread is broad, covering 9 countries, which provides strong cross-border validation of the care model.
Contact Stichting Radboud Universitair Medisch Centrum in the Netherlands
Talk to the team behind this work.
Contact us to explore licensing the PAL-CYCLES toolbox for your care facility.