Abstract
To analyze how the articulation between hospital and primary health care related to patient discharge and continuity of care after hospitalization takes place. Qualitative study, using the focus group technique to explore the experience of 21 nurses in hospitals (n = 10) and at primary care (n = 11) in a municipality in the northwest area of the State of São Paulo. Data collection took place between December 2019 and April 2020. Four focus groups were carried out (two in the hospital and two in the health units) and the findings underwent thematic analysis. The categories identified were: Patient inclusion flow in the responsible discharge planning, Patient/family member/caregiver participation, Care planning, Communication between services, and Challenges in the discharge process. According to reports, the discharge process is centered on bureaucratic aspects with gaps in communication and coordination of care. This research allowed understanding how nurses from different points of health care experience the discharge and (dis)articulation of the team work. The findings can equip managers in the (re)agreement of practices and integration of services to promote continuity of care.
Highlights
The Health Care Networks (RAS) encompass both actions and services articulated to promote equity, improve access, and ensure comprehensiveness and quality of care[1,2]
The municipality has five UBS and 24 Family Health Strategy (FHS) teams managed by a Social Health Organization (OS).The primary health care (PHC) nurses are hired by the OS and carry out the coordination of the unit and of the team(s), besides assuming the care demands
The first, “Flow of inclusion of the patient in the responsible discharge planning”, deals with the eligibility criteria and the moment of inclusion of the patient in the discharge planning and identifies, in the speech of some nurses from hospital care (HC), the decision still centered on the physician
Summary
The Health Care Networks (RAS) encompass both actions and services articulated to promote equity, improve access, and ensure comprehensiveness and quality of care[1,2]. The concept of continuity incorporates the patient’s perspective in the experience of care and combines three elements: information flow, interpersonal relationships, and intervention coordination[4]. It presupposes patients-health professionals interaction and connection sustained over time[5] and transition of care, that is, coordinated interventions between services during patient transference[6]. In Brazil, the responsible hospital discharge is a guideline[7] for transferring care from a specialized level (hospital) to other points in the RAS and provides for articulation of services, promotion of self-care, and implementation of de-hospitalization mechanisms. From the perspective of PHC, adversities in the referral and counter-referral system[10], failures in communication among teams[11], lack of workers’ knowledge about the functioning of RAS[12], little articulation[13], and difficulties in coordination of network care[14] are highlighted
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