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Mauro AD, Cucolo DF, Perroca MG. Hospital - primary care articulation in care transition: both sides of the process. Rev Esc Enferm USP 2021; 55:e20210145. [PMID: 34545910 DOI: 10.1590/1980-220x-reeusp-2021-0145] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2021] [Accepted: 07/20/2021] [Indexed: 11/22/2022] Open
Abstract
OBJECTIVE To analyze how the articulation between hospital and primary health care related to patient discharge and continuity of care after hospitalization takes place. METHOD Qualitative study, using the focus group technique to explore the experience of 21 nurses in hospitals (n = 10) and at primary care (n = 11) in a municipality in the northwest area of the State of São Paulo. Data collection took place between December 2019 and April 2020. Four focus groups were carried out (two in the hospital and two in the health units) and the findings underwent thematic analysis. RESULTS The categories identified were: Patient inclusion flow in the responsible discharge planning, Patient/family member/caregiver participation, Care planning, Communication between services, and Challenges in the discharge process. According to reports, the discharge process is centered on bureaucratic aspects with gaps in communication and coordination of care. CONCLUSION This research allowed understanding how nurses from different points of health care experience the discharge and (dis)articulation of the team work. The findings can equip managers in the (re)agreement of practices and integration of services to promote continuity of care.
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Affiliation(s)
- Adriéli Donati Mauro
- Faculdade de Medicina de São José do Rio Preto, Programa de Pós-graduação em Enfermagem, São José do Rio Preto, SP, Brazil
| | - Danielle Fabiana Cucolo
- Pontifícia Universidade Católica de Campinas, Programa de Pós-graduação, Campinas, SP, Brazil
| | - Marcia Galan Perroca
- Faculdade de Medicina de São José do Rio Preto, Programa de Pós-graduação em Enfermagem, São José do Rio Preto, SP, Brazil
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Groenvynck L, de Boer B, Hamers JPH, van Achterberg T, van Rossum E, Verbeek H. Toward a Partnership in the Transition from Home to a Nursing Home: The TRANSCIT Model. J Am Med Dir Assoc 2020; 22:351-356. [PMID: 33223451 DOI: 10.1016/j.jamda.2020.09.041] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2020] [Revised: 09/28/2020] [Accepted: 09/28/2020] [Indexed: 11/15/2022]
Abstract
The transition from home to a nursing home can be stressful and traumatic for both older persons and informal caregivers and is often associated with negative outcomes. Additionally, transitional care interventions often lack a comprehensive approach, possibly leading to fragmented care. To avoid this fragmentation and to optimize transitional care, a comprehensive and theory-based model is fundamental. It should include the needs of both older persons and informal caregivers. Therefore, this study, conducted within the European TRANS-SENIOR research consortium, proposes a model to optimize the transition from home to a nursing home, based on the experiences of older persons and informal caregivers. These experiences were captured by conducting a literature review with relevant literature retrieved from the databases CINAHL and PubMed. Studies were included if older persons and/or informal caregivers identified the experiences, needs, barriers, or facilitators during the transition from home to a nursing home. Subsequently, the data extracted from the included studies were mapped to the different stages of transition (pre-transition, mid-transition, and post-transition), creating the TRANSCIT-model. Finally, results were discussed with an expert panel, leading to a final proposed TRANSCIT model. The TRANSCIT model identified that older people and informal caregivers expressed an overall need for partnership during the transition from home to a nursing home. Moreover, it identified 4 key components throughout the transition trajectory (ie, pre-, mid-, and post-transition): (1) support, (2) communication, (3) information, and (4) time. The TRANSCIT model could advise policy makers, practitioners, and researchers on the development and evaluation of (future) transitional care interventions. It can be a guideline reckoning the needs of older people and their informal caregivers, emphasizing the need for a partnership, consequently reducing fragmentation in transitional care and optimizing the transition from home to a nursing home.
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Affiliation(s)
- Lindsay Groenvynck
- Faculty of Health Medicine and Life Sciences, Department of Health Services Research, CAPHRI Care and Public Health Research Institute, Living Lab of Ageing and Long Term Care, Maastricht University, Maastricht, the Netherlands; KU Leuven Department of Public Health and Primary Care, Academic Centre for Nursing and Midwifery, Leuven, Belgium.
| | - Bram de Boer
- Faculty of Health Medicine and Life Sciences, Department of Health Services Research, CAPHRI Care and Public Health Research Institute, Living Lab of Ageing and Long Term Care, Maastricht University, Maastricht, the Netherlands
| | - Jan P H Hamers
- Faculty of Health Medicine and Life Sciences, Department of Health Services Research, CAPHRI Care and Public Health Research Institute, Living Lab of Ageing and Long Term Care, Maastricht University, Maastricht, the Netherlands
| | - Theo van Achterberg
- KU Leuven Department of Public Health and Primary Care, Academic Centre for Nursing and Midwifery, Leuven, Belgium
| | - Erik van Rossum
- Faculty of Health Medicine and Life Sciences, Department of Health Services Research, CAPHRI Care and Public Health Research Institute, Living Lab of Ageing and Long Term Care, Maastricht University, Maastricht, the Netherlands; Academy of Nursing, Research Centre on Community Care, Zuyd University of Applied Sciences, Heerlen, the Netherlands
| | - Hilde Verbeek
- Faculty of Health Medicine and Life Sciences, Department of Health Services Research, CAPHRI Care and Public Health Research Institute, Living Lab of Ageing and Long Term Care, Maastricht University, Maastricht, the Netherlands
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