José Márcio Machado Batista|Carla Munhoz Pinheiro|Carla Madeira|Pedro Gomes|Óscar Ferreira|Cristina Lavareda Baixinho
Transitional Care Management from Emergency Services to Communities: An Action Research Study
Hospital Vila Franca de Xira|Hospital Vila Franca de Xira|Instituto Português de Oncologia Francisco Gentil|Lisbon School of Design|Instituto Politécnico de Leiria|Lisbon School of Design
recent years nurses developed projects area hospital community transition objective present study analyze transitional care offered elderly people used emergency services discharged return community action research method chosen participants nurses elderly people 70 years old older caregivers study carried october 2018 august 2019 data collected means semistructured interviews nurses analysis medical records participatory observation phone calls elderly people caregivers team meetings qualitative data submitted bardins content analysis statistical treatment carried applying spss version 230 institutions research ethics committee approved research 314 sample experienced care continuity discharge rate readmission emergency services first 30 days discharge 334 referral letters lacked data information provided patients caregivers nurses mentioned difficulties communication care levels well obstacles teamwork also mentioned lack health policies clinical rules formalize transitional care hospital community perpetuated noncoordination care two contexts low level literacy patients relatives mentioned cause understanding information regarding seeking primary health care services handing discharge letter concluded urgent need mobilize health teams toward action patients process returning home factor must taken account care planning