Health care transition: Key points for creating and implementing a project
DOI:
https://doi.org/10.31211/rpics.2023.9.1.290Keywords:
Health Care Transition, People-Centered Care, Patient Discharge, Best Practices, Qualitative StudyAbstract
Objective: Transitional care (TC) from hospital to home is a potential assessment indicator for the assessment of integrated and people-centered care. This qualitative exploratory-descriptive study aimed to identify principles of good practices in home-based TC after hospital discharge through content analysis of experiences shared by healthcare professionals in a workshop. Method: The workshop involved two moderators, four speakers, and 24 healthcare professionals divided into three groups. The speakers presented good practices in TC in healthcare, and the groups proposed TC strategies based on the speakers' presentations, their experiences, and their knowledge of healthcare. The proposals were recorded in audio and analyzed in terms of content. Results: According to the participants, the creation and implementation of a TC project involve contextualizing and defining the problem/need, objectives, target population, stakeholders and their roles, links, health-social-community partnerships, communication networks, and evaluation indicators of process and results. Conclusions: The importance of TC in hospital discharge was highlighted, providing insights for the creation and implementation of a successful TC project.
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Aase, K., & Waring, J. (2020). Crossing boundaries: Establishing a framework for researching quality and safety in care transitions. Applied Ergonomics, 89, Artigo 103228. https://doi.org/j7sd
Alqenae, F. A., Steinke, D., & Keers, R. N. (2020). Prevalence and nature of medication errors and medication-related harm following discharge from hospital to community settings: A systematic review. Drug Safety, 43(6), 517–537. https://doi.org/h8gr
Altfeld, S., Pavle, K., Rosenberg, W., & Shure, I. (2012). Integrating care across settings: The Illinois transitional care consortium’s bridge model. Generations Journal, 36(4), 98–101. https://bit.ly/3KJ6tvy
Bardin, L. (2011). Análise de conteúdo. Edições 70.
Braet, A., Weltens, C., & Sermeus, W. (2016). Effectiveness of discharge interventions from hospital to home on hospital readmissions: A systematic review. JBI Database of Systematic Reviews and Implementation Reports, 14(2), 106–173. https://doi.org/j54w
Brock, J., Jencks, S. F., & Hayes, R. K. (2021). Future directions in research to improve care transitions from hospital discharge. Medical Care, 59(Suppl 4), S401–S404. https://doi.org/j54x
Coleman, E. A., Mahoney, E., & Parry, C. (2005). Assessing the quality of preparation for posthospital care from the patient’s perspective: The care transitions measure. Medical Care, 43(3), 246–255. https://doi.org/b6x79g
Donabedian A. (1988). The quality of care. How can it be assessed?. JAMA, 260(12), 1743–1748. https://doi.org/fng27z
Escoval, A., Coelho, A., Diniz, J. A., Rodrigues, M., Moreira, F., & Espiga, P. (2010). Gestão integrada da doença: Uma abordagem experimental de gestão em saúde. Revista Portuguesa de Saúde Pública, Vol. Temático(9), 105–115. https://bit.ly/3GRaVr1
Feigenbaum, P., Neuwirth, E., Trowbridge, L., Teplitsky, S., Barnes, C. A., Fireman, E., Dorman, J., & Bellows, J. (2012). Factors contributing to all-cause 30-day readmissions: A structured case series across 18 hospitals. Medical Care, 50(7), 599–605. https://doi.org/f324gm
Fleming, M. O., & Haney, T. T. (2013). Improving patient outcomes with better care transitions: The role for home health. Cleveland Clinic Journal of Medicine, 80(1 e-suppl 1), e-S2-e-S6. https://doi.org/j54z
Flink, M., & Ekstedt, M. (2017). Planning for the discharge, not for patient self-management at home — An observational and interview study of hospital discharge. International Journal of Integrated Care, 17(6), Artigo 1. https://doi.org/gcrpqr
Fønss Rasmussen, L., Grode, L. B., Lange, J., Barat, I., & Gregersen, M. (2021). Impact of transitional care interventions on hospital readmissions in older medical patients: A systematic review. BMJ Open, 11(1), Artigo e040057. https://doi.org/j542
Fox, M. T., Persaud, M., Maimets, I., Brooks, D., O'Brien, K., & Tregunno, D. (2013). Effectiveness of early discharge planning in acutely ill or injured hospitalized older adults: A systematic review and meta-analysis. BMC Geriatrics, 13, 70. https://doi.org/gbdc6p
Geary, C. R., & Schumacher, K. L. (2012). Care transitions: Integrating transition theory and complexity science concepts. ANS. Advances in Nursing Science, 35(3), 236–248. https://doi.org/f37m4x
Goldstein, J. N., Hicks, L. S., Kolm, P., Weintraub, W. S., & Elliott, D. J. (2016). Is the care transitions measure associated with readmission risk? Analysis from a single academic center. Journal of General Internal Medicine, 31(7), 732–738. https://doi.org/f8wbnm
Hesselink, G., Schoonhoven, L., Plas, M., Wollersheim, H., & Vernooij-Dassen, M. (2013). Quality and safety of hospital discharge: A study on experiences and perceptions of patients, relatives and care providers. International Journal for Quality in Health Care: Journal of the International Society for Quality in Health Care, 25(1), 66–74. https://doi.org/f4ntpb
Hirschman, K. B., Shaid, E., McCauley, K., Pauly, M. V., & Naylor, M. D. (2015). Continuity of care: The transitional care model. Online Journal of Issues in Nursing, 20(3), Artigo 1. https://doi.org/j543
Kampstra, N. A., Zipfel, N., van der Nat, P. B., Westert, G. P., van der Wees, P. J., & Groenewoud, A. S. (2018). Health outcomes measurement and organizational readiness support quality improvement: A systematic review. BMC Health Services Research, 18(1), Artigo 1005. https://doi.org/j544
Kripalani, S., Jackson, A. T., Schnipper, J. L., & Coleman, E. A. (2007). Promoting effective transitions of care at hospital discharge: A review of key issues for hospitalists. Journal of Hospital Medicine, 2(5), 314–323. https://doi.org/fcpvhr
Mixon, A. S., Goggins, K., Bell, S. P., Vasilevskis, E. E., Nwosu, S., Schildcrout, J. S., & Kripalani, S. (2016). Preparedness for hospital discharge and prediction of readmission. Journal of Hospital Medicine, 11(9), 603–609. https://doi.org/f9bgz5
Ng, E., & de Colombani, P. (2015). Framework for selecting best practices in public health: A systematic literature review. Journal of Public Health Research, 4(3), 577. https://doi.org/gmcv4z
Opper, K., Beiler, J., Yakusheva, O., & Weiss, M. (2019). Effects of implementing a health team communication redesign on hospital readmissions within 30 days. Worldviews on Evidence-Based Nursing, 16(2), 121–130. https://doi.org/ghb562
Peikes, D., Lester, R. S., Gilman, B., & Brown, R. (2012). The effects of transitional care models on re-admissions: A review of the current evidence. Generations, 36(4), 44–55. https://bit.ly/3UHpHXh
Rennke, S., Nguyen, O. K., Shoeb, M. H., Magan, Y., Wachter, R. M., & Ranji, S. R. (2013). Hospital-initiated transitional care interventions as a patient safety strategy: A systematic review. Annals of Internal Medicine, 158(5 Pt 2), 433–440. https://doi.org/gfxptt
Sarmento, J., Siopa, M., Feteira-Santos, R., Lopes, S., Dias, S., Guerreiro, A. S., Panarra, A., Nascimento, P., Rodrigues, A., Rodrigues, A. C., Rocha, J. V., & Santana, R. (2022). Patients' perspectives on determinants avoidable hospitalizations: Development and validation of a questionnaire. International Journal of Environmental Research and Public Health, 19(5), Artigo 3138. https://doi.org/j545
Trompeter, J. M., McMillan, A. N., Rager, M. L., & Fox, J. R. (2015). Medication discrepancies during transitions of care: A comparison study. Journal for Healthcare Quality: Official Publication of the National Association for Healthcare Quality, 37(6), 325–332. https://doi.org/j546
Verhaegh, K. J., MacNeil-Vroomen, J. L., Eslami, S., Geerlings, S. E., de Rooij, S. E., & Buurman, B. M. (2014). Transitional care interventions prevent hospital readmissions for adults with chronic illnesses. Health Affairs (Project Hope), 33(9), 1531–1539. https://doi.org/f6mt37
World Health Organization. (2016). Transitions of care. World Health Organization. https://bit.ly/41yaUQC
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Copyright (c) 2023 Mónica Santos, Maria Inês Espírito Santo, Patricia Nascimento , Patricia Silva, Paula Rocha Saraiva, Paula Suarez Lopez (Autor)
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