Project K: Training for hospital-community safe transition

Abstract

Objective: To define the safe transition process from hospital to community of patients with chronic mental disorders and their families. Method: This was an action research study included in the constructivist paradigm. The participants in the study were nurses from a psychiatry service and from primary healthcare services. Results: After the identification of causes of continuity fragmentation, the following items emerged from the participants’ speeches: a) two criteria categories for safe transition (those associated with health status, dependence level, and self-care capacity of patients, and those associated with knowledge and competence level of informal caregivers); b) the design of an algorithm to facilitate clinical decision-making. Final considerations: In order to promote adherence to therapeutic treatment in the hospital-community transition, treatment plans must include patients and their families, and improve communication networks and support among care levels.

Transitional care to caregivers of dependent older people: an integrative literature review

“…Even studies on care continuity lack information about what the needs related to transitional care to caregivers are, which allows to corroborate the statement that the focus of interventions remains on older people, although it is known that caregivers are crucial in the process of transition to the home environment (12) . To change this situation, it is necessary that the focus of the planning of hospital discharge and return to home includes caregivers and the evaluation of their needs, to guarantee a safe transition from hospital to community for both dependent older people and caregivers (15)(16) .…”

“…People admitted to hospitals are vulnerable to experiencing care continuity loss when there are alterations in their health condition or when they are transferred between care institutions (16) . This poses a remarkable challenge for health systems to guarantee the execution of a set of actions whose objective is ensuring care continuity between different care levels (17) , which helps in the process of adapting to the new care reality (15)(16)(17) . Additionally, care continuity contributes to decreasing costs and is an adequate strategy and a policy to be replicated by health services (16) .…”

“…This poses a remarkable challenge for health systems to guarantee the execution of a set of actions whose objective is ensuring care continuity between different care levels (17) , which helps in the process of adapting to the new care reality (15)(16)(17) . Additionally, care continuity contributes to decreasing costs and is an adequate strategy and a policy to be replicated by health services (16) .…”

Caregiver burden and stress in psychiatric hospital admission

“…The restructuring of the Brazilian model of mental health care presents some challenges for a safe transition from hospital treatment to community treatment, such as the lack of educational interventions that help family caregivers to better understand the therapeutic treatment and to deal with mental disorders (33) .…”

Autopercepção Dos Estudantes Sobre a Participação Em Atividades Extracurriculares De Transferência De Conhecimento: O Exemplo Da Transição Segura

“…Conhecimento para a resolução de problemas dos diferentes serviços de internamento hospitalar para aumentarem o conhecimento e capacitarem os doentes e as suas famílias no processo de transição do hospital para a comunidade, favorecendo circuitos de comunicação que promovam a continuidade de cuidados, diminuindo os reinternamentos após a alta hospitalar, e promovendo a reabilitação e a inserção na comunidade (Paniagua et al, 2018;Ferreira et al, 2019).…”