Challenges in the implementation and evaluation of a transmural palliative care pathway for acutely hospitalized older adults; lessons from the PalliSupport program: A qualitative process evaluation study

•Initiating palliative care during hospitalization is considered to be inappropriate.•Transmural palliative care pathways should equally involve all care settings.•Implementation should start on a small scale to facilitate successful implementation.•Grant applications should make protocol adjustments and second pilot studies possible.•Simple study designs facilitate successful implementation of complex interventions. To improve transmural palliative care for acutely admitted older patients, the PalliSupport transmural care pathway was developed. Implementation of this care pathway was challenging. The aim of this study was to improve understanding why the implementation partly failed. A qualitative process evaluation study. :17 professionals who were involved in the PalliSupport program were interviewed. Online semi-structured interviews. Thematic analysis to create themes according to the implementation framework of Grol & Wensing. From this study, themes within four levels of implementation emerged: 1) The innovation: challenges in current palliative care, the setting of the pathway and boost for improvement; 2) Individual professional: feeling (un)involved and motivation; 3) Organizational level: project management; 4) Political and economic level: project plan and evaluation. We learned that the challenges involved in implementing a transmural care pathway in palliative care should not be underestimated. For successful implementation, we emphasize the importance of creating a program that fits the complexity of transmural palliative care. We suggest starting on a small scale and invest in project management. This could help to involve all stakeholders and anticipate current challenges in palliative care. To increase acceptance, create one care pathway that can start and be used in all care settings. Make sure that there is sufficient flexibility in time and room to adjust the project plan, so that a second pilot study can possibly be performed, and choose a scientific evaluation with both rigor and practical usefulness to evaluate effectiveness.