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

José Batista, Carla Munhoz Pinheiro, Carla Madeira, Pedro Gomes, Óscar Ramos Ferreira and Cristina Lavareda Baixinho
Additional contact information
José Batista: Vila Franca de Xira Hospital, 2600-009 Vila Franca de Xira, Portugal
Carla Munhoz Pinheiro: ACES Estuário do Tejo, 2630-242 Arruda dos Vinhos, Portugal
Carla Madeira: Vila Franca de Xira Hospital, 2600-009 Vila Franca de Xira, Portugal
Pedro Gomes: Portuguese Institute of Oncology, Nursing Research, Innovation and Development Centre of Lisbon, 1900-160 Lisbon, Portugal
Óscar Ramos Ferreira: Nursing School of Lisbon, Nursing Research, Innovation and Development Centre of Lisbon (CIDNUR), 1900-160 Lisbon, Portugal
Cristina Lavareda Baixinho: Nursing School of Lisbon, Nursing Research, Innovation and Development Centre of Lisbon (CIDNUR), 1900-160 Lisbon, Portugal

IJERPH, 2021, vol. 18, issue 22, 1-12

Abstract: 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.

Keywords: aged; caregivers; emergencies; emergency nursing; patient discharge; transitional care (search for similar items in EconPapers)
JEL-codes: I I1 I3 Q Q5 (search for similar items in EconPapers)
Date: 2021
References: View references in EconPapers View complete reference list from CitEc
Citations: View citations in EconPapers (1)

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