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:	José Batista, Carla Munhoz Pinheiro, Carla Madeira, Pedro Gomes, Óscar Ramos Ferreira, Cristina Lavareda Baixinho
Formato:	article
Lenguaje:	EN
Publicado:	MDPI AG 2021
Materias:	aged caregivers emergencies emergency nursing patient discharge transitional care Medicine R
Acceso en línea:	https://doaj.org/article/34b964d4a7a9405a9db1fa96093d846c
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spelling	oai:doaj.org-article:34b964d4a7a9405a9db1fa96093d846c2021-11-25T17:50:39ZTransitional Care Management from Emergency Services to Communities: An Action Research Study10.3390/ijerph1822120521660-46011661-7827https://doaj.org/article/34b964d4a7a9405a9db1fa96093d846c2021-11-01T00:00:00Zhttps://www.mdpi.com/1660-4601/18/22/12052https://doaj.org/toc/1661-7827https://doaj.org/toc/1660-4601In 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.José BatistaCarla Munhoz PinheiroCarla MadeiraPedro GomesÓscar Ramos FerreiraCristina Lavareda BaixinhoMDPI AGarticleagedcaregiversemergenciesemergency nursingpatient dischargetransitional careMedicineRENInternational Journal of Environmental Research and Public Health, Vol 18, Iss 12052, p 12052 (2021)
institution	DOAJ
collection	DOAJ
language	EN
topic	aged caregivers emergencies emergency nursing patient discharge transitional care Medicine R
spellingShingle	aged caregivers emergencies emergency nursing patient discharge transitional care Medicine R José Batista Carla Munhoz Pinheiro Carla Madeira Pedro Gomes Óscar Ramos Ferreira Cristina Lavareda Baixinho Transitional Care Management from Emergency Services to Communities: An Action Research Study
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.
format	article
author	José Batista Carla Munhoz Pinheiro Carla Madeira Pedro Gomes Óscar Ramos Ferreira Cristina Lavareda Baixinho
author_facet	José Batista Carla Munhoz Pinheiro Carla Madeira Pedro Gomes Óscar Ramos Ferreira Cristina Lavareda Baixinho
author_sort	José Batista
title	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_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_sort	transitional care management from emergency services to communities: an action research study
publisher	MDPI AG
publishDate	2021
url	https://doaj.org/article/34b964d4a7a9405a9db1fa96093d846c
work_keys_str_mv	AT josebatista transitionalcaremanagementfromemergencyservicestocommunitiesanactionresearchstudy AT carlamunhozpinheiro transitionalcaremanagementfromemergencyservicestocommunitiesanactionresearchstudy AT carlamadeira transitionalcaremanagementfromemergencyservicestocommunitiesanactionresearchstudy AT pedrogomes transitionalcaremanagementfromemergencyservicestocommunitiesanactionresearchstudy AT oscarramosferreira transitionalcaremanagementfromemergencyservicestocommunitiesanactionresearchstudy AT cristinalavaredabaixinho transitionalcaremanagementfromemergencyservicestocommunitiesanactionresearchstudy
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Transitional Care Management from Emergency Services to Communities: An Action Research Study

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