By Susanne Togeby, AAU Kommunikation og Public Affairs
Photo: Colourbox

As a patient in the Danish health system, you may experience being referred onwards without knowing who takes over, and whether the next professionals in the care pathway have the necessary information. This can create uncertainty and risk that patients do not receive the right care. For healthcare professionals, it may lead to duplication of work when patient data is not available or not clearly integrated into relevant workflows.

This is explained by Associate Professor Wendy Gunn, who leads a new project titled TRANSIT. The aim of the project is to create greater coherence and reassurance for patients when multiple parts of the health system are involved in their care.

“Transitions between hospital, municipality, and general practice are often a challenge. This can lead to misunderstandings, duplication of work, and uncertainty for patients, relatives, and healthcare professionals,” says Wendy Gunn.

One possible population of interest is patients with heart failure, where transitions between hospital, general practice, municipal care, and relatives are particularly critical.

In current practice, relevant information may be distributed across different systems, responsibilities may be unclear, and professionals may not always have the same understanding of what needs to happen next. Poor coordination may contribute to avoidable readmissions, unclear responsibilities, and reduced quality of care at home.

The project will explore where coordination between hospital, municipality, and general practice breaks down, what information needs to follow patients across sectors, and where closer coordination is needed. The goal is to identify solutions that strengthen coherence in care pathways without increasing documentation burden and administrative work for healthcare professionals.

Wendy Gunn emphasizes that the project does not aim to develop a standalone IT system. Instead, the seed phase examines how existing systems, workflows, responsibilities, and data practices can be better aligned to support coherent care transitions.