“Geriatric rehabilitation: development, implementation and evaluation of an integrated care pathway for patients with complex health problems”

Older adults who receive rehabilitation therapy in a geriatric rehabilitation care facility after being discharged from hospital and then receive aftercare in their home environment, come into touch with many care providers. This may result in a lack of continuity and coordination of care. A care pathway was developed and implemented in order to improve the integration of care offered by these facilities and care providers. Studies that constitute this dissertation show that after three months, the care pathway is effective in improving the frequency of performing daily activities among patients. The care pathway also resulted in a larger proportion of patients being discharged home after receiving geriatric rehabilitation care, a lower self-rated burden among informal caregivers after three months and cost savings.