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

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.

Factors Related to Family Caregivers’ Readiness for the Hospital Discharge of Advanced Cancer Patients

“…Such assistance can increase family caregivers' confidence and reduce care difficulty in providing post-discharge in-home care [24,65,66] and accommodate patients' desire to live at home [30,43,65]. For the above reasons, medical professionals should provide assessment and management based on the needs of the patient and family caregivers, including thorough evaluation and guidance regarding the knowledge and skills related to post-discharge in-home care [35,43,63,67], and should establish a telecare system and referral/handover system providing instruction and consultation to support family caregivers in providing post-discharge in-home care [15,36,[68][69][70]. Furthermore, transitional care programmes or home-based palliative care are practical implementations for advanced cancer patients and caregivers' discharge planning [64][65][66].…”

“…For family caregivers of these patients with advanced cancer, the factors influencing readiness for patients' hospital discharge are their patient's physical functioning, their perceptions of self-competence in managing the patient's symptom distress at home, the difficulties in responding to the patient's care problems, and proper support for them to undertake the patient's post-discharge care [5,11,12]. However, discharge preparations are not currently routinely in the hospital, and post-discharge support referrals are often poorly implemented [13][14][15].…”

Rehabilitation Nurse’s Perspective on Transitional Care: An Online Focus Group

“…(2) shared care and decision-making; (3) case management for people with complex needs; (4) services defined or with a single access point; (5) transitional or intermediate care; (6) integral service along the entire process; (7) technology to support continuity and coordination; (8) building the working capacity [1].…”

“…The articulation between care levels requires a multi and interdisciplinary team that ensures quality and safety, avoiding the decline of functionality in the post-discharge period and unnecessary rehospitalisations due to foreseeable risks and complications. Ensuring a safe transition from the hospital to the community is, for this reason, an appropriate strategy to be followed by the different health services, by the potential in promoting autonomy and independence for self-care [6][7][8]. Nevertheless, transition between care levels often cannot be planned, which leads to consequences in the preparation of patients and caretakers and contributes to hospital readmissions.…”

“…Nevertheless, transition between care levels often cannot be planned, which leads to consequences in the preparation of patients and caretakers and contributes to hospital readmissions. The reasons for readmission vary, but one of the most important components are assessment of community resources and whether they can fit patients' needs [7][8][9]. A French study estimated that, for patients 75 years old or older, hospital readmission rate within 30 days after discharge was 14%, and according to the researchers one quarter of these events was preventable [7].…”