Abstract
to map and synthesize the strategies implemented for case management in transitional care for patients with complex needs in emergency services. a scoping review conducted under the Joanna Briggs Institute guidance. Twenty-three studies were analyzed, with different methodological designs, on the strategies used in case management involving adult and elderly populations in emergency services. the main strategies employed were patient risk stratification screening/identification, care management plan, coordination of care through multidisciplinary activities, support for the transition process, continuous patient monitoring, and follow-up. these strategies used structured approaches to care in emergency services to promote support for self-management and effective transitional care for people with complex needs, ensuring comprehensiveness, coordination, and continuity of care.
Highlights
Studies show that health system users demand care transitions resulting from acute and chronic aggravated conditions(1-2). These individuals experience a combination of complex needs, resulting from coping with multimorbidity, mental health problems, and social vulnerability, which result in a pattern of extreme use of emergency services, with frequent and unnecessary hospitalizations(3-12)
The guiding question defined through PCC strategy (P - Population; C - Concept; and C - Context) was: what are the strategies for managing cases in the transitional care of patients with complex needs in emergency services? The investigated context involved serving frequent users of emergency services, with a history of multimorbidity, frequent hospitalizations, impaired mental health, and experiencing situations of social vulnerability(3,14)
Current case management models involve the conception of people-centered care, with the perspective of guaranteeing people effective continuity of health care
Summary
Studies show that health system users demand care transitions resulting from acute and chronic aggravated conditions(1-2). These individuals experience a combination of complex needs, resulting from coping with multimorbidity, mental health problems, and social vulnerability, which result in a pattern of extreme use of emergency services, with frequent and unnecessary hospitalizations(3-12). Despite the growing number of people with complex care and social needs, health care models that focus on illness in health systems still prevail. Transitional care approach is related to a comprehensive care plan; communication; safe use of medications; patient and family education to promote self-management; social and community support; participation of the multidisciplinary team to meet the complex care needs of patients; coordination of care; monitoring and follow-up(16-17)
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