Continuity of Hospital Discharge Care for Primary Health Care: Spanish Practice

Abstract

Objective: to understand discharge plan and the facilities and difficulties for continuity of care in Primary Health Care. Method: a qualitative and exploratory study carried out in Madrid, Barcelona, Murcia, Seville and Granada, with 29 hospital liaison nurses working in university hospitals, between 2016 and 2018. For data collection, an online questionnaire was used with open and closed questions about the profile of nurses; work context; hospital discharge plan; communication between hospital nurses and primary care. All were analyzed based on Thematic Analysis. Results: hospital liaison nurses from Spain draw up a discharge plan at least 48 hours in advance. They offer a Continuity of Care Report, guide patients, families and caregivers to the necessary care after hospital discharge, coordinate consultations and referrals and carry out home visits. Communication with primary care occurs through the computerized system and telephone. Monitoring takes place using indicators and statistical reports. In cases of readmission, nurses are requested and contacted by nurses in primary care. Communication with primary care is among the facilities. Lack of liaison nurses is among the difficulties. Conclusion: hospital liaison nurses from Spain carry out a discharge plan and communicate with primary care. When patients are hospitalized, they are called when there is a need for continuity of care for primary care.

Care Transtion in Hospital Discharge for Adult Patients: Integrative Literature Review

“…Some studies [63][64] reaffirmed the need for early discharge planning, which should be initiated upon the patient's admission. It is at this moment that all professionals involved in care should evaluate the social and health needs of the patient [63][64] , which can contribute to the discharge occurring at the planned time.…”

“…Authors stated that nurses are qualified to perform educational actions to promote health 70 and , during these moments, in addition to educating, it is necessary to detect the characteristics of the patient and family and collect information about their previous situation and the resources available 64 . Nurses are seen as the professionals who provide more complex care orientations to patients such as relief surveys, ostomies and extensive dressings 65 .…”

“…The creation of a tool to systematize hospital discharge, such as a continuity report, emphasizing the preparation that the patient had for discharge and that can be used as a care guide to be consulted at home, can be an effective strategy for the implementation of post-discharge care 6,64 . The elaboration of this type of tool requires collaboration and interdisciplinary work 6,64 and, often, nurses are the coordinator of this activity 6,64 .…”

“…The creation of a tool to systematize hospital discharge, such as a continuity report, emphasizing the preparation that the patient had for discharge and that can be used as a care guide to be consulted at home, can be an effective strategy for the implementation of post-discharge care 6,64 . The elaboration of this type of tool requires collaboration and interdisciplinary work 6,64 and, often, nurses are the coordinator of this activity 6,64 . This is already a reality in many countries and is related to the skills of nurses, who are recognized as an articulating link between patients and other professionals in the care team, as well as among the team's own professionals 7 .…”

Práticas de enfermeiros de um hospital universitário na continuidade do cuidado para a atenção primária

“…Dentre as fortalezas reveladas pelos participantes para a continuidade do cuidado está a comunicação entre os profissionais da equipe multiprofissional. Um estudo realizado na Espanha com EHE corroborou a comunicação como um elemento facilitador do processo de continuidade do cuidado, assim como a interação entre os profissionais e o trabalho em equipe 22 .…”