Transition of care of patients with chronic diseases and its relation with clinical and sociodemographic characteristics

Abstract

Objective: evaluate the transition of care from the perspective of people living with chronic diseases and identify its relation with clinical and sociodemographic characteristics. Method: cross-sectional study with 487 patients who were discharged from a hospital. Clinical and sociodemographic characterization instruments were used, as well as the Care Transitions Measure-15, which measures Preparation for self-management, Secured preferences, Understanding about medications and Care plan factors. Descriptive and inferential statistical analysis. Results: the transition of care was satisfactory (76.8±10.4). Average of the factors: Preparation for self-management (82.2±10.8), Secured preferences (84.7±14.3), Understanding about medications (75.7±13.7) and Care plan (64.5±13.2). Female patients had a higher average in the understanding about medications factor. Whites and residents in the urban area better evaluated the Care plan factor. The highest mean was observed for the Secured preferences factor (84.7±14.3) and the lowest for the Care plan factor (64.5±13.2). In all factors, significant differences were found in the variables (surgical patient, carrying clinical artifacts and not being hospitalized for COVID-19). Patients hospitalized for up to five days showed statistical difference in Preparation for self-management and Understanding about medications factors. In patients who were not readmitted within 30 days of discharge, Preparation for self-management was better. The better the Preparation for self-management, the lower the 30-day readmission rates. Conclusion: in patients living with chronic diseases, sociodemographic and clinical variables are associated with the transition of care. Patients who better evaluated preparation for self-management had fewer readmissions within 30 days.

Percepções da enfermagem frente ao planejamento de alta hospitalar de pessoas pós acidente vascular encefálico

“…Furthermore, it should be noted that the advances in preparing users for hospital discharge favor a quality service, and that follow-up after hospital discharge is of great value, making it possible to reduce new readmissions 4 and prepare patients to self-manage their post-discharge care while they are still hospitalized, which generally ends up reducing new admissions within 30 days of hospital discharge 22 . This highlights the need for strategies that contribute to the success of hospital discharge, minimizing the risk of failures in the continuity of care that result in readmissions.…”