Transitional care: analysis of the concept in hospital discharge management
Atención transicional: análisis de concepto en gestión de alta hospitalaria
Cuidados de transição: análise do conceito na gestão da alta hospitalar
Elizabeth Bernardino; Solange Meira de Sousa; Jaqueline Dias do Nascimento; Maria Ribeiro Lacerda; Danelia Gomez Torres; Luciana Schleder Gonçalves
Abstract
Objective: to analyze the concept of Transitional Care in the context of hospital discharge management.
Method: analytical reflection using the Walker and Avant's conceptual analysis: concept selection; definition of the objective, identification of the use of the concept (literature search and dictionaries between September-December/2019 in the databases: PubMed, Virtual Health Library and SCOPUS. A total of 77 articles that contemplated the concept and other terms that corroborated the study were considered; for methodological purposes, 12 studies enabled the analysis); definition of attributes; description of model case; description of additional cases; definition of antecedents and consequents; definition of empirical indicators.
Results: the fragmented care and readmission antecedents are common to the concept. The attributes integrated care, professional collaboration, coordination, discharge planning, communication, professional integration, and case management were identified.
Conclusion and Implications for practice: it was opportune to analyze the concept together with terms related to the context of hospital discharge. Transitional Care is coordinated and effective practices for the Continuity of Care in the transference of the user at hospital discharge; in this context, Liaison Nurses are potential protagonists to be ahead in this Integration process. The specificities of the concept may favor its understanding and the construction of knowledge that has repercussions on coordinated and continuous care.
Keywords
Resumen
Palabras clave
Resumo
Objetivo: analisar o conceito Cuidados de Transição no contexto da gestão da alta hospitalar.
Método: reflexão analítica utilizando-se a análise conceitual de Walker e Avant: seleção do conceito; definição do objetivo, identificação do uso do conceito (busca na literatura e dicionários entre setembro-dezembro/2019 nas bases de dados: PubMed, Biblioteca Virtual em Saúde e SCOPUS. Consideraram-se 77 artigos que contemplaram conceito e outros termos que corroboraram o estudo; para fins metodológicos, 12 estudos possibilitaram a análise); definição dos atributos; descrição de caso modelo; descrição de casos adicionais; definição de antecedentes e consequentes; definição de indicadores empíricos.
Resultados: os antecedentes cuidados fragmentados e reinternação são comuns ao conceito. Identificaram-se atributos cuidado integrado, colaboração profissional, coordenação, planejamento da alta, comunicação, integração profissional e gerenciamento de casos.
Conclusão e implicações para a prática: foi oportuno analisar o conceito em conjunto com termos relacionados ao contexto da alta hospitalar. Cuidados de Transição são práticas coordenadas e eficazes para a Continuidade dos Cuidados na transferência do usuário na alta hospitalar; nesse contexto, as Enfermeiras de Ligação são potenciais protagonistas para estar à frente nesse processo de Integração. As especificidades do conceito poderão favorecer a sua compreensão e a construção de conhecimentos que repercutam no cuidado coordenado e contínuo.
Palavras-chave
Referências
1 Walker LO, Avant KC. Strategies for theory construction in nursing. 6th ed. Nova York, NY (USA): Editora Person; 2019.
2 Fernandes M, da Nóbrega MM, Garcia TR, Macêdo-Costa KN. Conceptual analysis: methodological considerations. Rev Bras Enferm. 2011;64(6):1150-6.
3 Kuo YF, Goodwin JS. Association of hospitalist care with medical utilization after discharge: evidence of cost shift from a cohort study. Ann Intern Med. 2011;155(3):152-9.
4 Ribas EN, Bernardino E, Larocca LM, Poli P No, Aued GK, Silva CPCD. Nurse liaison: a strategy for counter-referral. Rev Bras Enferm. 2018;71(Suppl 1):546-53.
5 Costa MFBNAD, Andrade SR, Soares CF, Pérez EIB, Tomás SC, Bernardino E. The continuity of hospital nursing care for Primary Health Care in Spain. Rev Esc Enferm USP. 2019;53:e03477.
6 Aued GK, Bernardino E, Lapierre J, Dallaire C. Atividades das enfermeiras de ligação na alta hospitalar: uma estratégia para a continuidade do cuidado. Rev Lat Am Enfermagem. 2019;27:e3162.
7 Sousa SM, Bernardino E, Crozeta K, Peres AM, Lacerda MR. Integrality of care: challenges for the nurse practice. Rev Bras Enferm. 2017;70(3):504-10.
8 Portaria nº 3390 de 30 dezembro de 2013 (BR). Institui a Política Nacional de Atenção Hospitalar (PNHOSP) no âmbito do Sistema Único de Saúde (SUS), estabelecendo- se as diretrizes para a organização do componente hospitalar da Rede de Atenção à Saúde (RAS). Diário Oficial da União [periódico na internet], Brasília (DF), 2013 [citado 2020 out 15]. Disponível em:
9 Reidt SL, Holtan HS, Larson TA, Thompson B, Kerzner LJ, Salvatore TM et al. Interprofessional collaboration to improve discharge from skilled nursing facility to home: preliminary data on postdischarge hospitalizations and emergency department visits. J Am Geriatr Soc. 2016;64(9):1895-9.
10 Rattray NA, Sico JJ, Cox LM, Russ AL, Matthias MS, Frankel RM. Crossing the communication chasm: challenges and opportunities in transitions of care from the hospital to the primary care clinic. Jt Comm J Qual Patient Saf. 2017;43(3):127-37.
11 Hesselink G, Zegers M, Vernooij-Dassen M, Barach P, Kalkman C, Flink M et al. Improving patient discharge and reducing hospital readmissions by using intervention mapping. BMC Health Serv Res. 2014;14(1):389.
12 Fitzpatrick SJ, Perkins D, Handley T, Brown D, Luland T, Corvan E. Coordinating mental and physical health care in rural australia: an integrated model for primary care settings. Int J Integr Care. 2018;18(2):19.
13 Wodchis WP, Dixon A, Anderson GM, Goodwin N. Integrating care for older people with complex needs: key insights and lessons from a seven-country cross-case analysis. Int J Integr Care. 2015;15(6):e021.
14 Low LL, Vasanwala FF, Ng LB, Chen C, Lee KH, Tan SY. Effectiveness of a transitional home care program in reducing acute hospital utilization: a quasi-experimental study. BMC Health Serv Res. 2015;15:100.
15 Diplock G, Ward J, Stewart S, Scuffham P, Stewart P, Reeve C et al. The Alice Springs Hospital Readmission Prevention Project (ASHRAPP): a randomised control trial. BMC Health Serv Res. 2017;17(1):153.
16 Soto GE, Huenefeldt EA, Hengst MN, Reimer AJ, Samuel SK, Samuel SK et al. Implementation and impact analysis of a transitional care pathway for patients presenting to the emergency department with cardiac-related complaints. BMC Health Serv Res. 2018;18:672.
17 Lemetti T, Voutilainen P, Stolt M, Eloranta S, Suhonen R. An enquiry into nurse-to-nurse collaboration within the older people care chain as part of the integrated care: a qualitative study. Int J Integr Care. 2017;17(1):5.
18 Gholizadeh M, Janati A, Delgoshaei B, Gorji HA, Tourani S. Implementation requirements for Patient Discharge Planning in Health System: a qualitative study in Iran. Ethiop J Health Sci. 2018;28(2):157-68.
19 Ferreira ABH. Dicionário Aurélio da Língua Portuguesa. 5. ed. Curitiba: Positivo; 2010.
20 Nuño-Solinís R. Revisiting organisational learning in integrated care. Int J Integr Care. 2017;17(4):4.
21 Reid RJ, Haggerty J, Mckendry R. Defusing the confusion: concepts and measures of continuity of health care. [Internet]. Canadian Health Services Research Foundation; 2002 [citado 2020 out 15]. Disponível em:
22 Coleman EA, Boult CE, American Geriatrics Society Health Care Systems Committee. Improving the quality of transitional care for persons with complex care needs. J Am Geriatr Soc. 2003;51(4):556-7.
23 Vat M, Common C, Laizner AM, Borduas C, Maheu C. Reasons for returning to the emergency department following discharge from an internal medicine unit: perspectives of patients and the liaison nurse clinician. J Clin Nurs. 2015;24(23-24):3605-14.
24 Arts SE, Francke AL, Hutten JB. Liaison nursing for stroke patients: results of a Dutch evaluation study. J Adv Nurs. 2000;32(2):292-300.
25 Glimmerveen L, Nies H, Ybema S. Citizens as active participants in integrated care: challenging the Field’s dominant paradigms. Int J Integr Care. 2019;19(1):6.
26 Cloonan P, Wood J, Riley JB. Reducing 30-day readmissions: health literacy strategies. J Nurs Adm. 2013;43(7-8):382-7.
27 Kind AJH, Jensen L, Barczi S, Bridges A, Kordahl R, Smith MA et al. Low-cost transitional care with nurse managers making mostly phone contact with patients cut rehospitalization at a VA hospital. Health Aff (Millwood). 2012;31(12):2659-68.
28 Burke M. Transitional care. J Gerontol Nurs. 2009;35(12):3-4.
Submetido em:
04/11/2020
Aceito em:
14/08/2021
Facebook
Google+
Twitter
LinkedIn
Mendeley
StumbleUpon
CiteULike
Reddit
Email