Facilitating or hindering elements of the Care Transition process: na integrative review
DOI:
https://doi.org/10.33448/rsd-v10i11.19636Keywords:
Transitional care; Nursing; Primary helth care; Continuity of patient care; Comprehensive health care.Abstract
Objective: to summarize in the literature the elements that facilitate or hinder the transition of care from adult users from the perspective of nurses and/or users of surgical hospitalization services to the home or Primary Health Care. Materials and method: this is a integrative literature review. The search took place in January 2021, in the Latin American and Caribbean Literature in Health Sciences, National Library of Medicine/National Institutes of Health and SciVerse Scopus databases. For the selection of studies, the classification of levels of evidence was used. Results: A total of 731 productions were located, of which 23 made up the corpus of the study. The elements identified in the literature as facilitating or hindering the care transition process were: conducting discharge planning, outpatient follow-up, monitoring and managing symptoms after discharge, education and promotion of self-management, medication safety, organization, clarity, availability , timely information, communication and coordination of care between members of the health team. Conclusions: studies like this one are essential to give visibility to nurses in the transition of care, and to reflect on the importance of articulated work in networks at different levels of health care.
References
Coleman, E. A., & Boult, C. (2003) American Geriatrics Society Health Care Systems Committee. Improving the quality of transitional care for persons with complex care needs. J Am Geriatr Soc, 51(4):556-7.
Gunadi, S., Upfield, S., Pham, N. D., Yea, J., Schmiedeberg, M. B., & Stahmer, G. D. (2015). Development of a collaborative transitions-of-care program for heart failure patients. Am J Health-Syst Pharm,72(13):1147-52.
World Health Organization. (2016). Transitions of Care: Technical Series on Safer Primary Care. World Health Organization. https://apps.who.int/iris/bitstream/handle/10665/252272/9789241511599-eng.pdf;jsessionid=F02 F4867BC0581E4B21DE72B23FC0994?sequence=1
Burke, R. E., Kripalani, S., Vasilevskis, E. E., & Schnipper, J. L. (2013). Moving beyond readmission penalties: creating an ideal process to improve transitional care. J Hosp Med, 8(2):102-9.
Acosta, A. M., Lima, M. A. D., Marques, G. Q., Levandovski, P. F., & Weber, L. A. F. (2017). Brazilian version of the Care Transitions Measure: translation and validation. Int Nurs Rev, 64(3):379-87.
Gerhard, G., Yemane, A., Hickman, P., Oelschlaeger, A., Rollins, E., & Brennan, N. (2013). Data Shows Reduction in Medicare Hospital Readmission Rates During 2012. Medicare & Medicaid Research Review, 3(2).
Acosta, A. M. (2016). Transição do cuidado de pacientes com doenças crônicas: do serviço de emergência para o domicílio. Tese de doutorado, Programa de Pós-Graduação em Enferamgem, Universidade Federal do Rio Grande do Sul, Porto Alegre.
Martins, K. P., Costa, K. N., Macedo, K. N. F., Oliveira, D. S. T., Valdevino, S. C., & Rezende, L. C. (2015). Nurse's role on preparing for discharge of surgical patients. J. res.: fundam. Care, 07(1):1756-1764.
Melnyk, B. M., & Fineout-Overhol, T. E. (2011). Evidence-based practice in nursing & healthcare. A guide to best practice. Philadelphia:Lippincot Williams & Wilkins.
Rebollo, G. A. M., Álvarez, A. I., Fernández, G. C. L., Arondo, K. M. I., Alonso, C. E., & Colina, A. A. (2017). Integration of primary health care in outpatient surgery programs. Kirubide Project. Cir. mayor ambul, 22(4), 199–201.
Lee, J. S., Gonzales, R., Vittinghoff, E., Corbett, K. K., Fleischmann, K. E., Sehgal, N., & Auerbach, A. D. (2017). Appropriate Reconciliation of Cardiovascular Medications After Elective Surgery and Postdischarge Acute Hospital and Ambulatory Visits. J Hosp Med, 12(9), 723–730.
Cunha, K. S., Higashi, G. D. C., Erdmann, A. L., Kahl, C., Koerich, C., & Meirelles, B. H. S. (2016) Myocardial revascularization: factors intervening in the reference and counter-reference in Primary Health Care. TT. Esc. Enferm. USP, 50(6), 965–972.
Travieso, M. J. M. & Ruiz, A. J. M. (2009). Proceso asistencial hipertrofia benigna de próstata-cáncer de próstata: papel de enfermería de atención primaria en la implantación, desarrollo y control de calidad del processo/No disponible. ENFURO: Rev. Asoc. Esp. A.T.S. Urol, 110, 10–12.
Brooke,. B. S., Beckstrom, J., Slager, S. L., Weir, C. R. & Del Fiol, G. (2019). Discordance in Information Exchange Between Providers During Care Transitions for Surgical Patients. J Surg Res, 244, 174–180.
Aued, G. K., Bernardino, E., Lapierre, J. & Dallaire, C. (2019). Liaison nurse activities at hospital discharge: a strategy for continuity of care. Rev. Latino-Am. Enfermagem, 27,3162.
Kind, A. J. H., Jensen, L., Barczi, S., Bridges, A., Kordahl, B., Smith, M. A., & Asthana, S. (2012). Low-Cost Transitional Care With Nurse Managers Making Mostly Phone Contact With Patients Cut Rehospitalization At A VA Hospital. Health Affairs (Project Hope), 31(12), 2659–2668.
Langelaan, M., Baines, R. J., Bruijne, M. C. & Wagner, C. (2017). Association of admission and patient characteristics with quality of discharge letters: posthoc analysis of a retrospective study. BMC Health Services Research, 17:225
Horstman, M. J., Mills, W. L., Herman, L. I., Cai, C., Shelton, G., Qdaisat, T., Berger, D. H., & Naik, A. D. (2017). Patient experience with discharge instructions in postdischarge recovery: a qualitative study. BMJ Open, 7(2), 014842.
Meredith, P. & Emberton, M. (2000). The NHS patient information lottery: it is whom you see rather than what you need. Annals of The Royal College of Surgeons of England, 82(3), 217–222.
Van Walraven, C., Taljaard, M., Bell, C. M., Etchells, E., Zarnke, K. B., Stiell, I. G., & Forster, A. J (2008). Information exchange among physicians caring for the same patient in the community. CMAJ: Canadian Medical Association Journal, 179(10), 1013–1018.
Hardiman, K. M., Reames, C. D., McLeod, M. C. & Regenbogen, S. E. (2016). A Patient-Autonomy-Centered Self-Care Checklist Reduces Hospital Readmissions After Ileostomy Creation. Surgery, 160(5), 1302–1308.
Wahlberg, H., Braaten, T. & Broderstad, A. R. (2016). Impact of referral templates on patient experience of the referral and care process: A cluster randomised trial. BMJ Open, 6(10).
Carrillo, G., Mesa, M., Gómez, O.J., Numpaque, O. & Laguna, M. (2019). Educational intervention (CUIDAR) in cancer patients treated with surgery: A quasi-experimental study. Patient Education and Counseling, 102(8), 1475–1482.
Keller, G., Merchant, A., Common, C. & Laizner, A. M. (2017). Patient experiences of in-hospital preparations for follow-up care at home. Journal of Clinical Nursing, 26(11–12), 1485–1494.
Dash, I. & Pickering, G. T. (2017). Improving post-operative communication between primary and secondary care: The wound closure information card. Primary Health Care Research and Development, 18(1), 92–96.
Acher, A. W., Lecaire, T. J., Hundt, A. S., Greenberg, C. C., Carayon, P., Kind, A. J., & Weber, S. M. (2015). Using human factors and systems engineering to evaluate readmission after complex surgery. Journal of the American College of Surgeons, 221(4), 810–820.
Hall, M. H., Esposito, R. A., Pekmezaris, R., Lesser, M., Moravick, D., Jahn, L., Blenderman, R., Akerman, M., Nouryan, C. N., & Hartman, A. R. (2014) Cardiac surgery nurse practitioner home visits prevent coronary artery bypass graft readmissions. Annals of Thoracic Surgery, 97(5), 1488–1495.
Brooke, B. S, Stone, D. H., Cronenwett, J. L., Nolan, B., De Martino, R. R., MacKenzie, T. A., Goodman, D. C., & Goodney P. P. (2014). Early primary care provider follow-up and readmission after high-risk surgery. JAMA Surgery, 149(8), 821–828.
Dal, Ü., Bulut, H. & Demir, S. G. (2012). The problems experienced by the patients at home after surgery. Medical Journal of Bakirkoy, 8(1), 34–40.
Herrera, E. C., Rodríguez, A. M. D. M., Navarro, E. J. L., Godoy, M. A., García, P. A., Rodríguez, J. G., & Sánchez, I. R. (2011). Effect of a telephone care program after hospital discharge from a trauma surgery unit. Gaceta Sanitaria, 25(2), 133–138.
Morin, D., Aubin, M., Vezina, L., Gagnon, J., Racine, S., Reinharz, D., Paradis, M., Dallaire, C., & Aubin, K. (2009). From hospital to home after cardiac surgery: Evaluation of a community nursing care management model. Professional Case Management, 14(4), 167–175.
Theobald, K. & McMurray, A. (2004). Coronary artery bypass graft surgery: Discharge planning for successful recovery. Journal of Advanced Nursing, 47(5), 483–491.
Portaria nº 2.436, de 21 de setembro de 2017 (2017). Aprova a Política Nacional de Atenção Básica, estabelecendo a revisão de diretrizes para a organização da Atenção Básica, no âmbito do Sistema Único de Saúde (SUS). https://bvsms.saude.gov.br/bvs/saudelegis/gm/2017/prt2436_22_09_2017.html.
Downloads
Published
How to Cite
Issue
Section
License
Copyright (c) 2021 Danieli Bandeira; Teresinha Heck Weiller; Adalvane Nobres Damaceno; Vanessa Rodrigues Pucci; Elisa Rucks Megier; Geraldo de Freitas de Souza Junior
This work is licensed under a Creative Commons Attribution 4.0 International License.
Authors who publish with this journal agree to the following terms:
1) Authors retain copyright and grant the journal right of first publication with the work simultaneously licensed under a Creative Commons Attribution License that allows others to share the work with an acknowledgement of the work's authorship and initial publication in this journal.
2) Authors are able to enter into separate, additional contractual arrangements for the non-exclusive distribution of the journal's published version of the work (e.g., post it to an institutional repository or publish it in a book), with an acknowledgement of its initial publication in this journal.
3) Authors are permitted and encouraged to post their work online (e.g., in institutional repositories or on their website) prior to and during the submission process, as it can lead to productive exchanges, as well as earlier and greater citation of published work.
