Hospital at Home as a stress test for integrated care at UZ Leuven, Jessa Hospital and Wit-Gele Kruis

Hospital at Home is growing rapidly, but it confronts hospitals and primary care with a fundamental challenge: how do you organise high-quality transmural care without creating additional complexity? Integrated care requires more than goodwill and smooth communication. As soon as clinical follow-up, registration and reporting shift to the home setting, informal collaboration is no longer sufficient. The care process must then follow a clear organisational and digital flow.

In practice, healthcare organisations and professionals encounter fragmented information, different software systems, varying registration logics and unclear agreements about who follows up what, and when. Hospital at Home makes these bottlenecks explicitly visible, as follow-up, logistics and responsibility no longer remain within a single organisation or workflow. UZ Leuven and Jessa Hospital approach Hospital at Home not as a sum of initiatives, but as one integrated care pathway. Through the subsidised pilot projects OPAT (Outpatient Parenteral Antimicrobial Therapy) and Hospital at Home Oncology, they developed two concrete care pathways in which hospital and primary care do not operate alongside each other, but within one shared process.

In this interview, UZ Leuven, Wit-Gele Kruis Vlaams-Brabant, Jessa Ziekenhuis and Nexuzhealth jointly map out what integrated care looks like in practice, which agreements are required, and how the centralised electronic health record (EHR) of Nexuzhealth makes the difference.

“There are many different software systems in the healthcare landscape. Within care lines they function perfectly well, but as soon as you want to collaborate transmuraly, several problems arise,” says Olivier Schottey, Product Owner at Nexuzhealth. “By consistently placing the patient at the centre, we have succeeded in collaborating smoothly and efficiently across care settings within an integrated care pathway. The pilot projects around OPAT and Hospital at Home Oncology prove this.”

Increasingly more Hospital at Home

“In oncological treatments, you often mobilise the patient’s entire environment for an administration or injection,” says Annemarie Coolbrandt, Clinical Nurse Specialist at UZ Leuven. “Travelling to the day centre requires considerable effort from both the patient and family members, while the care contact at that moment often revolves solely around the administration itself.” This reflection has been ongoing for years, but gained momentum due to capacity pressure, a clearer framework and financial support from the government.

“That is why we recently launched Hospital at Home Oncology in collaboration with Nexuzhealth and Wit-Gele Kruis Vlaams-Brabant.” Lotte Vander Elst, Clinical Pharmacist at UZ Leuven, sees the same logic in OPAT. “Intravenous antibiotic therapy is generally initiated in hospital or on an outpatient basis. Once the patient is clinically stable and further admission is no longer necessary, treatment and follow-up can safely continue at home.”

Elke De Troy, Chief Pharmacist at Jessa Ziekenhuis, frames it from a rational perspective. “If a treatment can safely take place at home, it is first and foremost more comfortable for the patient. Moreover, it is no longer feasible, nor necessary, to organise all long-term intravenous antibiotic therapies in hospital. OPAT creates valuable capacity gains for the hospital, which we can deploy for patients who require more acute care. It is therefore important to build a safe and efficient working method in which all involved healthcare professionals remain informed about the progress of a treatment. In 2026, Jessa will fully roll out the same flow together with Wit-Gele Kruis Limburg and structurally anchor it in the collaboration.”

Vision article

The journey towards integrated care, from hospital to the home setting

From collaborating to integrated working

In conversations about transmural care, communication is often mentioned. “Communication is obviously important, but integrated working primarily means thinking together about what everyone needs and how to organise that in practice,” says Jany Coenen, Policy Advisor Digital Care at Wit-Gele Kruis Vlaams-Brabant. “The hospital does not delegate to primary care; you remain jointly responsible. That reciprocity is new and crucial.” This means redesigning the care process as one chain, with clear tasks, expectations and rules. “It also requires that you do not regard primary care as an executor, but as a partner who feeds back clinically relevant information, even when everything is going well.”

More than 90% of nurses with OPAT experience rate the new way of working as better to much better than before. Staff experience the workflow as more efficient and clearer, with a lower administrative burden.

Jany Coenen

Staff Member Digital Care at Wit-Gele Kruis

Stakeholder management

Interoperability is another key term. “At Nexuzhealth, we have invested heavily in this in recent years. Today, we are reaping the benefits,” Olivier Schottey continues. “In these pilot projects, the main challenge was not to develop the flows we designed too specifically. We had to remain constantly alert to ensure that the flows are broadly applicable and suitable for multiple hospitals. By consciously choosing broadly deployable flows, we are building a platform that is scalable across hospitals and that enables innovation to happen faster and more consistently.”

From fragmentation to one care pathway

Without an integrated workflow, information becomes fragmented across different channels, in PDFs and through manual registrations. That used to be daily reality. “It is not that long ago that everything was still paper-based,” says Jany Coenen. “We had to complete documents, scan them and send them by email. Only now do you realise how vulnerable such a chain is. By digitalising and working in an integrated way, the language of care and the language of IT move closer together. What does a care task entail? Which parameters do we need? It is extremely important to speak the same language.” Annemarie Coolbrandt nods. “That was not as straightforward as it may seem. The substantive reflection on data sharing in Hospital at Home was developed in consultation with other hospitals and primary care partners. The technical translation of this was then intensively elaborated in close collaboration between UZ Leuven, Wit-Gele Kruis Vlaams-Brabant and Nexuzhealth.”

Jany Coenen points to the complexity behind that seemingly simple objective. “We use eHealthBox to communicate securely, but everyone uses different parameters and terminology. That requires underlying coding and mapping. That uniformity sometimes lies in small details, such as using the same pain scale.” Olivier Schottey nods. “That is why at Nexuzhealth we use the international HL7 FHIR standard and SNOMED CT codes. By doing so, we deliberately lay the foundation for interoperability, reusability and scalability of care processes, including across hospital boundaries.”

By always putting the patient at the centre, we have succeeded in collaborating smoothly and efficiently across care settings within an integrated care pathway. This is demonstrated by the pilot projects on OPAT and Hospital at Home Oncology.

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Olivier Schottey

Product Owner at Nexuzhealth

Lotte Vander Elst emphasises that uniform agreements are crucial for transmural working. “Four major agreements were necessary to work uniformly: which questions you ask per care pathway, which codes you use, which international standards you follow and how that information is correctly exchanged with the other party. We ultimately chose SNOMED CT, FHIR and eHealthBox.”

Elke De Troy and Lotte Vander Elst underline why the preparatory work through working groups was so important. “For users, it is essential that as much as possible runs through the centralised electronic health record (EHR). The treating physician does not always have visibility on how things are going at home. With digital follow-up, everything flows directly into the record. You gain more insight, you are alerted more quickly in case of deviations and you reduce the risk of errors. In other words, follow-up improves and becomes more efficient.”

Case: Hospital at Home with OPAT

OPAT (Outpatient Parenteral Antimicrobial Therapy) enables patients to receive their intravenous antibiotics at home. The treating physician and the OPAT care team closely monitor these patients. The starting point is clear: anyone who is clinically stable does not need to remain in hospital for a treatment that can safely continue at home, provided that follow-up is well organised.

Comparison: before and now

Lotte Vander Elst compares the previous and current working methods. “Previously, when the physician indicated that a patient could go home, we informed the patient and the OPAT care team initiated collaboration with home nursing. All information was sent by email to the home care organisation, including the prescription, information leaflets and a separate follow-up document listing all the parameters we wished to monitor.

In practice, that meant weekly administrative hassle: printing documents, completing them, scanning them and sending them by email. In case of alarm signals, a telephone consultation followed. Deviations were then manually recorded in the hospital record and communicated back to home nursing.”

In the current way of working at UZ Leuven, OPAT has shifted to a digital interaction starting from the centralised electronic health record (EHR). “We now create a digital certificate in the record, which eliminates the paper prescription. As digital questionnaires have also been created, the requested parameters are received automatically in digital form, making the separate follow-up document redundant. The parameters registered by home nursing are recorded in a structured way in the correct location. Telephone follow-up obviously remains in place for situations requiring direct alignment, but email communication has been completely eliminated. This shifts the core of follow-up from manual, periodic feedback to continuous, record-linked information that is immediately usable for the care team. Moreover, everything is significantly safer.”

At Wit-Gele Kruis Vlaams-Brabant, this translates into a semi-automated flow supporting nurses during the care moment. Jany Coenen explains: “The prescription is received via eHealthBox, and for a known patient it immediately appears in the correct department. Scheduling still needs to be done manually, but after that much runs automatically. Based on the prescription, questionnaires are triggered. The nurse knows which parameters need to be monitored and, after confirmation of the visit, a coded message is automatically sent back to the hospital.”

Jany Coenen mainly notices the impact on time and attention. “We recently surveyed this. More than 90 percent of nurses with OPAT experience rate the new way of working as better to much better than before. Staff experience the process as more efficient and clearer, with a lower administrative burden.”

What about abnormal parameters?

“If a home nurse registers an abnormal value, consultation with the hospital is required,” explains Annemarie Coolbrandt. “But feedback is also important when everything is going well. We remain legally obliged, from the hospital’s perspective, to monitor all home administrations.”

Jany Coenen describes how this is supported technically and procedurally. “With a care confirmation, a questionnaire is always sent along, even in case of cancellation. In case of abnormal values, the hospital immediately receives that information and the nurse automatically receives a notification to make contact. That telephone contact is subsequently also registered.”

Case: Hospital at Home Oncology

Hospital at Home Oncology resembles OPAT, but involves slightly more variation. Annemarie Coolbrandt explains: “An oncological treatment pathway is long and requires many treatment appointments and close monitoring. If a cycle lasts four weeks, for example, hospital appointments that are only necessary for the injection can be replaced by home administration. Communication also tends to go back and forth more frequently in oncology patients. Home nurses must also assess therapy-related complaints, such as nerve damage or neuropathy. It is not one size fits all, so treatment-specific questionnaires are required.”

What stands out is that UZ Leuven deliberately approaches hospital at home as one integrated, digital care pathway, with OPAT and hospital at home Oncology as examples. Annemarie Coolbrandt emphasises that this reflection was also necessary to prevent each care pathway from becoming an isolated island. “If developed separately, we would quickly have ended up with different concepts and agreements. By building this together, you create something that is reusable and scalable.”

For patients, the added value is often immediately visible. Jany Coenen explains: “Patients mainly say that their therapy fits better into their daily lives, as they need to travel less frequently. Also keep in mind that for some people a hospital experience can be traumatic. In that case, home care makes a significant difference.”

First results

Wit-Gele Kruis Vlaams-Brabant recently conducted an internal survey on the implementation of transmural communication. The new way of working is generally received positively by nurses and administrative staff. For OPAT, the majority experience the prescription as better to much better, particularly in terms of accessibility and clarity. The integrated questionnaire is described as user-friendly and supportive, and more than half indicate that the administrative burden has decreased. For Hospital at Home Oncology, more than 80 percent of home nurses rate the new way of working as better to much better, again with positive scores for accessibility, clarity and completeness. The reduction in administrative workload is less pronounced there.

Scaling towards a standard

Those involved point to two conditions for genuine scaling. The first is co-creation. Jany Coenen explains: “We are now seeing a proliferation of initiatives that resemble transmural collaboration, but they are not always based on co-creation. We need to jointly examine the role of the hospital care team and the nurse at home. That operating principle is crucial for the future.” The second condition is standardisation. Jany Coenen strongly believes in the way these projects were set up, but warns of a potential pitfall. “Because it is possible, you risk asking too much. That is not always an added value. The importance lies in what you need to ask.” That is why international standards are not a detail. They are the binding element that ensures a patient in Limburg can be supported in the same way as a patient in Vlaams-Brabant.

“That is why at Nexuzhealth we use the international HL7 FHIR standard and SNOMED CT codes. By working with these standards, we deliberately lay the foundation for interoperability, reusability and scalability of care processes, also beyond hospital boundaries.”

Olivier Schottey

Product Owner at Nexuzhealth

Conclusion

Hospital at Home is more than shifting care to the home environment. It is a stress test for integrated care. OPAT and Hospital at Home Oncology demonstrate that it only becomes scalable when clinical follow-up, logistics, communication and registrations are designed together, with clear agreements and a shared language. The centralised electronic health record (EHR) makes it possible to close that chain without reverting to emails with PDF files and manual uploads.

What is currently being built at Nexuzhealth, UZ Leuven, Wit-Gele Kruis, i-mens and Jessa Hospital, and at the same time at, among others, AZ Diest, RZ Heilig Hart Tienen, Imelda Bonheiden and AZ Sint-Jan Brugge, is a model that can help other hospitals to start more quickly, standardise more intelligently and, above all, make transmural collaboration truly integrated. As one care pathway that works for everyone, including beyond the walls of a hospital.

HEALTHCARE FACILITY/HOSPITAL