[Challenges in geriatric rehabilitation: the development of an integrated care pathway].

Coordination and continuity of care within geriatric rehabilitation is challenging. To tackle these challenges, an integrated care pathway within geriatric rehabilitation care (hospital, geriatric rehabilitation and follow-up care in the home situation) has been developed. The aim of this article is to expound the process of developing the integrated care pathway, and to describe and discuss the results of this process (which is the integrated care pathway). Developing the integrated care pathway was done by the guidance of the first four steps of the theoretical framework for implementation of change from Grol and Wensing: (1) development of a specific proposal for change in practice; (2) analysis of current care practice; (3) analysis of the target group and setting; and (4) development and selection of interventions/strategies for change. The organizations involved in geriatric rehabilitation argued that the integrated care pathway should focus on improving the process of care, including transfer of patients, handovers and communication between care organizations. Current practice, barriers and incentives for change were analyzed through literature research, expert consultation, and interviews with the involved caregivers and by establishing working groups of health care professionals, patients and informal caregivers. This resulted in valuable proposals for improvement of the care process, which were gathered and combined in the integrated care pathway. The integrated care pathway entails agreements on (a) the triage process in the hospital; (b) active engagement of patients and informal caregivers in the care process; (c) timely and high quality handovers; and (d) improved communication between caregivers.