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

José Batista,Óscar Ramos Ferreira,Pedro Gomes,Cristina Lavareda Baixinho,Carla Madeira,Carla Munhoz Pinheiro

doi:10.3390/ijerph182212052

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.

Highlights

The number of people 65 years old or older is expected to increase from 524 million in 2010 to nearly 1.5 billion in 2050 [1], which means there will be changes in health indicators, and this impacts the search for health care
‘When we receive discharge letters from the hospital, we evaluate the level of urgency of the situation, but these patients often need medical care and we have only one doctor, who has one afternoon a week to go to the patients’ houses to evaluate and prescribe’
The ageing process, which is associated with the high prevalence of chronic diseases and accidents, leads to increased demand for emergency services by older people and their caregivers

Summary

Introduction

The number of people 65 years old or older is expected to increase from 524 million in 2010 to nearly 1.5 billion in 2050 [1], which means there will be changes in health indicators, and this impacts the search for health care. Health-disease transitions and the alterations in functioning resulting from aging, which is made worse by comorbidities, influence elderly people’s quality of life and increase the chances of their becoming dependent on other people [1] to carry out self-care. Changes in the epidemiological profile of people who resort to hospital care draw attention to the need to apply different care models to guarantee individualization of care of sick elderly people, as well as of their caregivers. This implies ensuring proper care transition to informal caregivers and deploying social and community resources [2,3] that.

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