Development of the transmural allied healthcare pathway (TULIP) – an intervention mapping approach

Development of the transmural allied healthcare pathway (TULIP) – an intervention mapping approach | Research Square Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Development of the transmural allied healthcare pathway (TULIP) – an intervention mapping approach J. W.M. van Grootel, R. J. Collet, J. M. van Dongen, M. van der Leeden, and 4 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8133659/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 5 You are reading this latest preprint version Abstract Background Hospital-to-home transitions for patients with complex allied healthcare needs are often fragmented, with limited structured, theory-informed approaches to support multidisciplinary collaboration. While Intervention Mapping (IM) has been applied in health intervention development, few studies address complex, transmural care pathways. This study describes the systematic development of a transmural allied healthcare pathway to optimize hospital-to-home transitions, using IM. Methods A development study was conducted following the first four steps of IM. Stakeholders from the Amsterdam University Medical Center and allied healthcare professionals from primary care in the Amsterdam region were involved throughout the process. The first four steps of IM were followed 1) a needs assessment was conducted, 2) the logic model of the problem was translated into the logic model of change, 3) theory-based intervention methods were selected , and 4) the intervention program was developed. Results The needs assessment identified key issues affecting transitional care such as unclear role division, delayed identification of patients requiring allied healthcare, fragmented communication across settings, and insufficiently tailored patient and family involvement. These findings informed a logic model of the problem, corresponding performance objectives, and the logic model of change. The resulting intervention, TULIP, aims to strengthen collaboration and communication across hospital and primary care. TULIP consists of six components: early patient identification, appointment of a coordinator, family involvement, improved discharge summaries, referral within allied healthcare networks, and structured post-discharge follow-up. Conclusions This study shows how a structured, theory-informed approach can be used to develop a transmural allied healthcare intervention for hospital-to-home transitions. The resulting TULIP blueprint provides healthcare professionals with concrete, adaptable components that can strengthen collaboration, improve information exchange, and support consistent allied healthcare involvement across settings. TULIP offers a practical intervention that organizations can tailor to their local workflows. Future studies should assess its feasibility, (cost-)effectiveness, and sustainability in routine practice. Intervention mapping transitional care collaboration allied healthcare hospital primary care Figures Figure 1 Figure 2 Figure 3 Key Message Using Intervention Mapping, we developed TULIP: a six-component transmural allied healthcare intervention to improve collaboration across hospital and primary care. TULIP offers a practical, adaptable model for organizations aiming to strengthen hospital-to-home transitions; future studies will evaluate its feasibility and impact. Background Patients with complex healthcare needs often experience fragmented care, characterized by an uncoordinated delivery of healthcare services across multiple providers, particularly during hospital-to-home transitions. This might result in poorer health-related outcomes and avoidable readmissions ( 1 , 2 ). These patients typically suffer from multiple chronic conditions, mental health problems, drug interactions, and social vulnerability, all of which hinder care coordination and continuity ( 3 ). For example, hospital-to-home transitions are often hampered by an overload of information that does not stick, insufficient family involvement, and difficulties navigating the healthcare system ( 4 , 5 ). A multidisciplinary, patient-centered approach, including services such as physiotherapy, occupational therapy, dietetics, and speech therapy, together with the support of a case manager overseeing the transition process has been shown to improve care coordination, reduce readmissions, and enhance patient outcomes ( 6 , 7 ). However, allied healthcare professionals require clear role definitions and task division to deliver high-quality care during these transitions ( 4 , 8 ). Furthermore, there is a need for more effective multidisciplinary communication, which could be facilitated by innovative information technologies (e.g., a shared digital communication platform) to ensure optimal coordination and care continuity ( 9 ). To address the aforementioned challenges, developing and implementing integrated, patient-centered, multidisciplinary transitional care interventions has become a priority for many healthcare settings ( 7 , 10 ). Multidisciplinary transitional care interventions generally include components such as; early identification of patients' care needs, improved communication between hospital and primary care professionals, and tailored support to help patients and families ( 11 , 12 ). Evidence from recent systematic reviews highlights the potential of these interventions for improving health-related outcomes, reducing readmissions and mortality, and being cost-effective ( 13 ). However, designing and implementing multidisciplinary transitional care interventions is complex, because they must address the needs of multiple stakeholders across different settings simultaneously. Hence, systematic planning is essential to maximize the chances of their successful and sustainable implementation. The Intervention Mapping framework (IM) is a widely used systematic approach to design, implement, and evaluate healthcare interventions ( 14 – 17 ). Although IM has been applied in various settings, few studies illustrate its use for complex, multidisciplinary transitional care interventions involving both hospital and primary care allied healthcare professionals. Existing literature rarely addresses the development of structured transmural pathways, the integration of multiple allied healthcare disciplines, or the systematic involvement of diverse stakeholders in intervention design. This paper presents the development of the TransmUral alLied healthcare Pathway (TULIP) using IM, demonstrating a novel methodological application that addresses these gaps. The IM approach we used to develop TULIP will provide clinicians and researchers globally with a practical guide to facilitate the successful and sustainable development and implementation of similar interventions in their own settings. Materials and Methods Design The IM approach is structured into six iterative steps: ( 1 ) Needs assessment , which involves identifying the problem, its determinants, and stakeholders' needs; ( 2 ) Program objectives , defining measurable outcomes based on the needs assessment; ( 3 ) Theory-based methods and strategies , involving the selection of methods and theories to design intervention components; ( 4 ) Program development , including necessary materials, activities, and delivery methods; ( 5 ) Implementation plan , selecting strategies to ensure effective delivery and adoption of the intervention; and ( 6 ) Evaluation plan , which includes process and outcome evaluations to assess and refine the intervention ( 16 , 17 ). This paper focuses on the first four steps of IM, as they are essential for establishing an intervention (Table 1 ). The implementation and evaluation of TULIP will be presented in a separate publication. Table 1 Intervention Mapping steps and actions Step Action 1. Logic model of the problem 1) creating planning groups; 2) conducting a needs assessment, 3) describing the local context, 4) stating program goals 2. Logic model of change 1) stating expected behavioral- and environmental outcomes, 2) specifying performance objectives, 3) selecting personal determinants, 4) specifying change objectives, 5) combining this in one overview (logic model of change) 3. Program design 1) generate program themes, 2) choose theory- and evidence-based change methods, 3) design practical applications 4. Program production 1) refine program structure, 2) prepare plans for materials/protocols, 3) draft messages, materials and protocols, 4) pretest and produce materials 5. Program implementation plan 1) identify program implementers, 2) state outcomes and objectives, 3) construct matrices of change, 4) design implementation interventions 6. Evaluation Plan 1) write effect and process evaluation, develop indicators for assessment, 3) specify evaluation design, 4) complete evaluation plan Setting TULIP was developed for two wards of the Amsterdam University Medical Center (AUMC), Internal medicine and Trauma surgery and primary care settings in the Amsterdam region. The AUMC Medical Ethics Review Committee granted a waiver (2024.0512). The research complied with the Declaration of Helsinki and did not involve the collection of identifiable personal data; therefore, informed consent was not required. Timespan This four-year TULIP project started in January 2023 with an extensive needs assessment. The intervention development took place between January 2024 and January 2025, and will be followed by its implementation and evaluation from February 2025 to December 2026. Reporting standards Reporting of the intervention development followed the GUIDED (Guidance for Reporting Intervention Development Studies in Health Research) checklist to enhance transparency, reproducibility, and alignment with implementation science standards. The final intervention is described in detail according to the TIDieR (Template for Intervention Description and Replication) checklist. Step 1: Logic model of the problem A needs assessment was conducted using qualitative and quantitative methods (Fig. 1 ). First, focus groups and interviews were conducted to explore the experiences, perceptions, and needs of patients and professionals regarding hospital-to-home transitions ( 4 , 18 , 19 ). Second, we conducted four systematic reviews examining stakeholders’ experiences, the (cost-)effectiveness of multidisciplinary transitional care interventions, and the barriers and facilitators to their successful implementation ( 11 – 13 , 20 ). Using the PRECEDE-PROCEED model ( 21 ), findings were translated into a logic model of the problem that summarized the main issues that allied healthcare professionals are facing. Our stakeholder group included researchers, allied healthcare professionals from hospital and primary care, nurses, medical doctors, managers, ICT staff, patients and their families. We focused primarily on allied health professionals in hospital and primary care, as they were expected to undergo the most substantial behavioral changes within TULIP. We also gathered insights into the local context and existing programs relevant to TULIP, which informed the formulation of the program goals. Step 2: Logic model of change This step provides the foundation for TULIP by clearly describing the changes it aims to achieve. The matrices describe how modifying determinants such as improving knowledge of each other’s roles or increasing confidence in cross-setting communication, could strengthen collaboration and ultimately improve patient transitions. Because such determinants may differ across settings, the matrices were tailored healthcare professionals involved in this project but structured to support adaptation in other contexts ( 22 ). Step 3: Program design Program themes emerging from the needs assessment such as early identification, coordinated communication, and family involvement, guided the prioritization of determinants. Theoretical change methods were selected from the IM framework ( 17 ) and translated into practical applications. Practical applications were designed to be feasible by taking into account the characteristics of the healthcare professionals in both the hospital and primary care setting, as well as insights from successful strategies identified during the needs assessment ( 11 ). Step 4: Program production In this step, TULIP was developed based on the results from steps 1–3. For this purpose, the results of step 1–3 were first discussed and checked within the research team to ensure that everything was properly integrated. Then, to address the diverse needs of allied healthcare professionals, TULIP was divided into six components. To ensure a tailored approach, each component was assessed for its applicability to the respective wards through discussions with healthcare professionals. Their feedback was discussed within meetings with the research team and refined the components. Results Step 1: Logic model of the problem A detailed description of the needs assessment results from our qualitative studies and literature reviews is provided elsewhere ( 4 , 11 , 12 , 18 – 20 ). In summary, patients emphasized the importance of being actively involved in transitional care decisions. Discharge was often experienced as sudden, leaving patients feeling emotionally and physically unprepared. Families were seen as essential partners who understood the home environment and could assist in arranging follow-up care ( 4 , 12 ). Patients also reported difficulties in recalling and processing information provided close to discharge. The amount of information was overwhelming and often delivered at a moment when attention was focused on going home; understanding was not consistently checked. Despite these challenges, patients felt well supported by allied healthcare professionals during admission, valuing the continuity created by collaboration among these professionals ( 4 , 12 ). Healthcare professionals highlighted the need for clear role definitions and coordinated task division, timely discharge planning, and structured referrals within specialized allied healthcare networks ( 12 , 18 , 19 ). Both patients and professionals noted gaps in collaboration and information exchange between hospital and primary care settings. Patients described one-way communication, while professionals emphasized the need for uniform, structured information transfer embedded in routine workflows ( 12 , 18 , 19 ). Findings from our systematic reviews further indicated that multidisciplinary transitional care interventions have the potential to reduce readmissions and mortality, improve quality of life and physical functioning, and reduce healthcare and societal costs ( 11 – 13 , 20 ). Together, these insights informed the development of the logic model of the problem (Fig. 2 ). The needs assessment also provided us with information about related initiatives within the AUMC, other hospitals, and the primary care setting. Examples include a project optimizing the hospital-to-home transition from a nursing perspective and one promoting nutrition and physical activity during hospitalization with weekly allied healthcare meetings. Through discussions with the leaders of these initiatives we facilitated mutual learning and collaboration. Where possible, TULIP was integrated with these initiatives to ensure efficiency. Based on the needs assessment, program goals were defined at the patient, professional, and organizational levels, including improving patient functioning, strengthening collaboration, and reducing avoidable hospital utilization. Step 2: Logic model of change Based on the information gathered in step 1, the logic model of the problem was transformed into a logic model of change (see Supplementary file A) specifying the desired behavioral outcomes and the determinants that need to be addressed to achieve them ( 17 ). The result of TULIP is optimized collaboration and communication between healthcare professionals from different settings, which in turn supports transitional care for patients with allied healthcare needs. For hospital-based allied healthcare professionals, performance objectives included coordinated discharge planning, effective handovers to primary care, and involvement of families when appropriate. These performance objectives were linked to key determinants such as knowledge of available services, confidence in interprofessional communication, skills to use standardized tools, and positive expectations regarding collaborative transitional care. Table 2 presents the matrices of performance objectives and determinants for hospital-based allied healthcare professionals. Similar matrices were developed for primary care professionals and for patients and families (Supplementary files B and C). Together, these matrices outline the specific behavioral changes required to address the problems identified in Step 1. Table 2 Performance objectives, determinants and change objectives for hospital allied healthcare professionals Behavioral/environmental outcomes: Hospital allied healthcare professionals taking their role in transitional care Personal determinants Performance Objectives Knowledge Skills and Self-efficacy Attitude Outcome expectations PO1. Hospital professionals identify patients with allied healthcare needs after hospitalization K1. Define signs of patients who may require allied healthcare after hospitalization SS1. Demonstrate ability to use a flowchart tool to identify patients with allied healthcare needs after hospitalization A1. Recognize the value of identifying patients with allied healthcare needs after discharge O1. Expect that identifying patients will result in enrolling patients in a transmural allied healthcare pathway PO2. Hospital professionals participate in multidisciplinary meetings on the ward to discuss allied healthcare needs after hospitalization K2. State the roles and responsibilities of different healthcare professionals on the ward in the discharge process SS2. Express confidence in participating in a multidisciplinary meeting on the ward A2. Recognize the value of multidisciplinary coordination and collaboration O2. Expect that active participation of hospital professionals in multidisciplinary meetings focused on discharge planning contributes to optimized transitional care PO3. Hospital professionals involve patients and their families in transitional care K3. List strategies on how to involve patients and families in transitional care SS3. Demonstrate empathy and active listening skills to address patient and family preferences A3. Express positive feelings about the effectiveness of collaborative partnerships between healthcare professionals, patients, and families O3. Expect that the intervention can foster a culture of patient and family-centered care during transitions, leading to improved transitional care PO4. Hospital professionals conduct a uniform, complete discharge letter, and have interaction with their primary care colleague K4. List the components that should be included in a discharge letter to ensure a comprehensive information transfer SS4. Showing proficiency in using electronic communication systems and formats for online transmission of discharge letters A4. Feel positive about the efficacy of online communication methods for transmitting discharge letters securely and efficiently O4. Expect that consistency and completeness of discharge letters, leads to better information transfer and coordination of care between settings PO5. Hospital professionals refer their patients within specialized allied healthcare networks K5. List the available specialized allied healthcare services and networks in the Amsterdam region SS5. Demonstrate the ability to navigate the referral process and facilitate seamless transitions of care for patients - O5. Expect that referral of patients to specialized allied healthcare networks leads to more comprehensive and coordinated care PO6. Hospital professionals monitor their patients after hospitalization K6. Recognize their role in monitoring patients after hospitalization SS6. Showing proficiency in conducting (telephone) follow-up for patients after hospitalization - O6. Expect that monitoring patients can improve patient and healthcare professionals' satisfaction of transitional care Step 3: Program design In the third step, we decided ‘how’ to achieve the objectives identified in step two by selecting theoretical change methods provided by IM and translating them into practical applications to influence the behavior and the environment ( 17 ). Three determinants emerged as most important and modifiable: knowledge, skills and self-efficacy, and attitudes and outcome expectations ( 4 , 12 , 13 , 18 ). To strengthen knowledge, we developed practical tools such as checklists, ward posters, a standardized handover template, newsletters, and an online platform with infographics ( 23 , 24 ). To improve skills and self-efficacy, we incorporated clinical instruction sessions and structured feedback moments in which professionals could practice tasks, ask questions, and reflect on their experiences with TULIP ( 25 ). To influence attitudes and outcome expectations, we identified local champions who acted as role models and supported colleagues during the early stages of implementation ( 26 ). Step 4: Program production In step 4, TULIP was developed and consisted of six components: 1) Identification of patients who need allied healthcare services, 2) Appointing a coordinator, 3) Family involvement, 4) Improved discharge summary, 5) Referring within allied healthcare networks and 6) Structured (telephone) follow-up (Fig. 3 ). Each component is supported by a delivery channel through which TULIP is delivered (e.g. digital communication platform, or conversation). All components were linked to the results of our needs assessment, per discharge phase (hospitalization, bridging and post-discharge) ( 11 , 12 ). Components were refined in iterative sessions with allied healthcare professionals from both hospital and primary care. Their feedback led to the outline of the digital communication platform, clearer terminology, and a structured approach to connect with colleagues from different settings. The blueprint with detailed information about TULIP can be found in Supplementary file D. Hospitalization phase: When the patient is admitted to the hospital. Bridging phase: From discharge planning to patient preparation for discharge. Post-discharge phase: After discharge, at home or in a (geriatric) rehabilitation center. We also identified several barriers including: including limited time, staff turnover, budget constraints, primary care waiting lists, and hospital bed pressure. We addressed these challenges by integrating TULIP into existing workflows, setting clear selection criteria, and designing the intervention so it could be delivered without additional personnel. Anticipated reductions in readmissions may contribute to its long-term sustainability. Discussion This paper describes the development of a hospital-to-home transmural allied healthcare intervention to facilitate collaboration between healthcare professionals and improve continuity of allied healthcare after hospitalization. Based on the literature, empirical research, behavior change theories following IM and multiple discussions, TULIP was developed. The intervention includes six components, 1) Identification of patients who need allied healthcare services, 2) Appointing a coordinator, 3) Family involvement, 4) Improved discharge summary, 5) Referring within allied healthcare networks and 6) Structured (telephone) follow-up. Our study contributes to the growing body of literature on transitional care interventions. Previous research has demonstrated that structured transitional care, often involving coordination, systematic discharge planning, and follow-up, can reduce readmissions, enhance patient functioning, and lower healthcare costs ( 13 , 27 ). Many of these interventions were developed for specific patient groups, such as oncology or neurology, and often focused on medical or nursing transitions rather than on allied healthcare ( 28 – 30 ). In contrast, TULIP addresses the entire transitional care process from an allied healthcare perspective and was designed for a broader patient population, irrespective of diagnosis or medical specialty. By focusing specifically on allied healthcare professionals across both hospital and primary care settings, this study highlights the role of allied healthcare professionals, an area that has received less empirical attention even though it is crucial for supporting patient functioning during hospital-to-home transitions. Our results could serve as a blueprint for clinicians and researchers to facilitate the implementation of similar interventions in their own settings. Professionals should then assess whether the findings from our needs assessment align with their specific context. We do not recommend conducting an entirely new needs assessment, as there is extensive literature available, and the process is time-intensive ( 4 , 11 – 13 , 27 ). Instead, one could evaluate each component of TULIP to determine its adaptability to their own setting. For instance, if a digital communication platform is not available, one might consider delivering its content through alternative delivery channels. We encourage professionals to critically evaluate ongoing projects in their own setting and align them with the steps presented in this research. This study has several strengths and limitations. One strength is the comprehensive needs assessment, which took about two years to complete and involved all relevant stakeholders. Additionally, the intervention was developed using the iterative steps of IM, which will enhance its (cost-)effectiveness because of its theory- and evidence-based approach. The developed TULIP intervention included six components, which implies a moderate complex intervention, that facilitates its implementation as well ( 27 ). However, a limitation is the generalizability of our results to patient groups for whom healthcare pathways are not yet available. As a consequence, each component of the intervention should be carefully evaluated by researchers and clinicians within a specific population to determine its applicability, and adjusted if needed ( 31 , 32 ). Additionally, at this moment our study focuses on hospital-to-home transitions involving allied healthcare professionals, without integrating medication or nursing handovers into the intervention. Further research is needed to establish how these aspects could also be integrated. Another limitation is the presence of barriers associated with the implementation of the intervention that are beyond our control. Examples of such factors are that the study covers most of the costs, staff turnover, and waiting lists in primary care are challenges we cannot directly address. These issues may affect the intervention's success. Future research should focus on assessing the impact of TULIP. For that, further efforts are required to complete steps 5 and 6 of the IM process. Step 5 involves the selection of implementation strategies, which will be supported by the Expert Recommendations of Implementing Change (e.g. appointing champions, develop educational materials) ( 31 ). In step 6, an evaluation plan will be developed, guided by the Reach, Effectiveness, Adoption, Implementation, and Maintenance framework, with evaluation outcomes aligned with the project goals ( 32 ). Once the impact is proven, integrating TULIP with the transfer of medical information could be a valuable next step. Conclusions In summary, we developed a theory-informed, transmural allied healthcare pathway using IM to strengthen multidisciplinary collaboration and improve hospital-to-home transitions for patients with allied healthcare needs. This study illustrates how IM can be applied within a complex, multi-setting context and delivers a practical, replicable blueprint that organizations can adapt to enhance service coordination. Future research should evaluate the feasibility, effectiveness, and long-term sustainability of this pathway across diverse healthcare settings. Declarations Ethics approval statement : The AUMC Medical Ethics Review Committee granted a waiver (2024.0512). The research complied with the Declaration of Helsinki. Informed consent statement : This study did not involve the recruitment of human participants. As such, the requirement for obtaining informed consent was not applicable. Conflict of interest statement: None. Funding statement: This project is funded by ZonMw, grant numbers: 10270022110008 and 10270022110004. Author Contribution J. van Grootel: conceptualization, methodology, validation, writing original draft, visualization, project administration, writing review and editing. R. Collet: conceptualization, validation, writing review and editing, visualization. J.M. van Dongen: conceptualization, validation, writing review and editing, visualization. E. Geleijn: conceptualization, writing review and editing. M. van der Leeden: conceptualization, validation, writing review and editing. S. Wiertsema: conceptualization, writing review and editing. R. Ostelo: conceptualization, writing review and editing. M. van der Schaaf: conceptualization, methodology, writing review and editing, investigation, project administration, supervision. Acknowledgements: No acknowledgments to declare. Data availability statement: As this study primarily reports the development of an intervention using the Intervention Mapping framework, no individual participant data were collected. Additional materials, including the logic models, matrices of change objectives, and TIDieR checklist, are available in the supplementary files. References Kangovi S, Barg FK, Carter T, Levy K, Sellman J, Long JA, et al. Challenges faced by patients with low socioeconomic status during the post-hospital transition. J Gen Intern Med. 2014;29(2):283–9. Weeks LE, Macdonald M, Martin-Misener R, Helwig M, Bishop A, Iduye DF, et al. The impact of transitional care programs on health services utilization in community-dwelling older adults: a systematic review. JBI Database Syst Rev Implement Rep. 2018;16(2):345–84. Schaink AK, Kuluski K, Lyons RF, Fortin M, Jadad AR, Upshur R, et al. A scoping review and thematic classification of patient complexity: offering a unifying framework. 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Glasgow RE, Harden SM, Gaglio B, Rabin B, Smith ML, Porter GC et al. RE-AIM Planning and Evaluation Framework: Adapting to New Science and Practice With a 20-Year Review. Front Public Health. 2019;7. Additional Declarations No competing interests reported. Supplementary Files supplementaryfiles.docx Cite Share Download PDF Status: Under Review Version 1 posted Reviewers invited by journal 27 Nov, 2025 Editor invited by journal 24 Nov, 2025 Editor assigned by journal 21 Nov, 2025 Submission checks completed at journal 21 Nov, 2025 First submitted to journal 17 Nov, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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