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Transitional Care Management from Emergency Services to Communities: An Action Research Study

In recent years, nurses have developed projects in the area of hospital to community transition. The objective of the present study was to analyze the transitional care offered to elderly people after they used emergency services and were discharged to return to the community. The action research me...

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Autores principales: Batista, José, Pinheiro, Carla Munhoz, Madeira, Carla, Gomes, Pedro, Ferreira, Óscar Ramos, Baixinho, Cristina Lavareda
Formato: Online Artículo Texto
Lenguaje:English
Publicado: MDPI 2021
Materias:
Acceso en línea:https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8624079/
https://www.ncbi.nlm.nih.gov/pubmed/34831807
http://dx.doi.org/10.3390/ijerph182212052
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author Batista, José
Pinheiro, Carla Munhoz
Madeira, Carla
Gomes, Pedro
Ferreira, Óscar Ramos
Baixinho, Cristina Lavareda
author_facet Batista, José
Pinheiro, Carla Munhoz
Madeira, Carla
Gomes, Pedro
Ferreira, Óscar Ramos
Baixinho, Cristina Lavareda
author_sort Batista, José
collection PubMed
description In recent years, nurses have developed projects in the area of hospital to community transition. The objective of the present study was to analyze the transitional care offered to elderly people after they used emergency services and were discharged to return to the community. The action research method was chosen. The participants were nurses, elderly people 70 years old or older, and their caregivers. The study was carried out from October 2018 to August 2019. The data were collected by means of semi-structured interviews with the nurses, analysis of medical records, participatory observation, phone calls to the elderly people and caregivers, and team meetings. The qualitative data were submitted to Bardin’s content analysis. Statistical treatment was carried out by applying SPSS version 23.0. The institution’s research ethics committee approved the research. Only 31.4% of the sample experienced care continuity after discharge, and the rate of readmission to emergency services during the first 30 days after discharge was 33.4%. The referral letters lacked data on information provided to patients or caregivers, and nurses mentioned difficulties in communication between care levels, as well as obstacles to teamwork; they also mentioned that the lack of health policies and clinical rules to formalize transitional care between the hospital and the community perpetuated non-coordination of care between the two contexts. The low level of literacy of patients and their relatives are mentioned as a cause for not understanding the information regarding seeking primary health care services and handing the discharge letter. It was concluded that there is an urgent need to mobilize health teams toward action in the patients’ process of returning home, and this factor must be taken into account in care planning.
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spelling pubmed-86240792021-11-27 Transitional Care Management from Emergency Services to Communities: An Action Research Study Batista, José Pinheiro, Carla Munhoz Madeira, Carla Gomes, Pedro Ferreira, Óscar Ramos Baixinho, Cristina Lavareda Int J Environ Res Public Health Article In recent years, nurses have developed projects in the area of hospital to community transition. The objective of the present study was to analyze the transitional care offered to elderly people after they used emergency services and were discharged to return to the community. The action research method was chosen. The participants were nurses, elderly people 70 years old or older, and their caregivers. The study was carried out from October 2018 to August 2019. The data were collected by means of semi-structured interviews with the nurses, analysis of medical records, participatory observation, phone calls to the elderly people and caregivers, and team meetings. The qualitative data were submitted to Bardin’s content analysis. Statistical treatment was carried out by applying SPSS version 23.0. The institution’s research ethics committee approved the research. Only 31.4% of the sample experienced care continuity after discharge, and the rate of readmission to emergency services during the first 30 days after discharge was 33.4%. The referral letters lacked data on information provided to patients or caregivers, and nurses mentioned difficulties in communication between care levels, as well as obstacles to teamwork; they also mentioned that the lack of health policies and clinical rules to formalize transitional care between the hospital and the community perpetuated non-coordination of care between the two contexts. The low level of literacy of patients and their relatives are mentioned as a cause for not understanding the information regarding seeking primary health care services and handing the discharge letter. It was concluded that there is an urgent need to mobilize health teams toward action in the patients’ process of returning home, and this factor must be taken into account in care planning. MDPI 2021-11-17 /pmc/articles/PMC8624079/ /pubmed/34831807 http://dx.doi.org/10.3390/ijerph182212052 Text en © 2021 by the authors. https://creativecommons.org/licenses/by/4.0/Licensee MDPI, Basel, Switzerland. This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY) license (https://creativecommons.org/licenses/by/4.0/).
spellingShingle Article
Batista, José
Pinheiro, Carla Munhoz
Madeira, Carla
Gomes, Pedro
Ferreira, Óscar Ramos
Baixinho, Cristina Lavareda
Transitional Care Management from Emergency Services to Communities: An Action Research Study
title Transitional Care Management from Emergency Services to Communities: An Action Research Study
title_full Transitional Care Management from Emergency Services to Communities: An Action Research Study
title_fullStr Transitional Care Management from Emergency Services to Communities: An Action Research Study
title_full_unstemmed Transitional Care Management from Emergency Services to Communities: An Action Research Study
title_short Transitional Care Management from Emergency Services to Communities: An Action Research Study
title_sort transitional care management from emergency services to communities: an action research study
topic Article
url https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8624079/
https://www.ncbi.nlm.nih.gov/pubmed/34831807
http://dx.doi.org/10.3390/ijerph182212052
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