Transitional rehabilitation care and patient care continuity as an advanced nursing practice

Transition of care in post-hospitalization patients due to covid-19 in a hospital in northeastern Brazil

OBJECTIVE

To analyze the transition of care for post-hospitalization patients due to covid-19 in a hospital in northeastern Brazil.

METHODS

Quantitative, cross-sectional, descriptive, and analytical study carried out between 2020 and 2021. The sample had 78 patients. Data collection took place by telephone with the support of a sociodemographic questionnaire and the care transition assessment instrument (Care Transitions Measure).

RESULTS

The average length of stay was 24.04 days. The average score for care transition was 71.68 (±11.71). "Self-management training" and "Understanding of medications" had higher averages, 75.15 (±13.76) and 74.10 (±16.20).

CONCLUSIONS

The average length of stay was 24.04 days. The average score for care transition was 71.68 (±11.71). "Self-management training" and "Understanding of medications" had higher averages, 75.15 (±13.76) and 74.10 (±16.20).

Telerehabilitation in the Transitional Care of Patients with Sequelae Associated with COVID-19: Perception of Portuguese Nurses

The COVID-19 pandemic brought many changes and challenges to health professionals, due to a lack of knowledge when dealing with the disease, fear of contagion, and the sequelae that characterize long COVID. To deal with this situation, respiratory rehabilitation programs are recommended in face-to-face and/or telerehabilitation modalities. (1) Background: This study had as its primary aim identifying the aspects/components to be considered in the planning and implementation of telerehabilitation interventions that guarantee transitional care for people with long COVID-19 after hospitalization and as a secondary aim identifying the positive aspects of telerehabilitation. (2) Methods: The method used to answer the research question was a focus group, carried out online with eight nurses specialized in rehabilitation nursing. The answers to the semi-structured interview were subjected to content analysis, and qualitative data analysis software (WebQDA^®) was used to organize and analyze the findings. (3) Results: Four categories emerged from the content analysis: coordination between care levels; transitional care telerehabilitation intervention; advantages of telerehabilitation; and opportunities. (4) Conclusions: These findings make an important contribution to the reorganization of transitional care, allowing the identification of central aspects to be considered in the planning and implementation of telerehabilitation programs for people with long COVID.

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

The increasing incidence of chronic and dependence leads to the need for hospitalization and adaptation in the process of returning home, as well as transition between care levels to ensure continuity of care. The World Health Organization has been warning about this problem since 2016, and consider reorganizing the care model as one of the solutions. The present study aimed to analyse the nurses’ perspective on transitional care for dependent people with rehabilitation care needs after hospital discharge. Methods: A focus group was developed with the participation of Rehabilitation Nurses from the hospital and community context, and content analysis was defined a posteriori. Results: From the content analysis emerged four related categories: promotion of continuity of care, nurse of advanced practice as a care manager, capacitation of the person and caregiver, and promotion of the care coordination. Conclusions: The present study allowed the strategies identification that minimize fragmentation risk of care and promote the person participation in transitional care. Ensuring transitional care is imperative to increase the quality of care, the satisfaction of professionals, clients, and the development of a system of sustainable health.