Trabalho, Educação e Saúde - TES (Work, Education and Health) is an open access scientific journal, edited by the Joaquim Venâncio Polytechnic School of Health, from Oswaldo Cruz Foundation.
Ministério da Saúde (2013)

Transition and continuity of care after hospital discharge from the perspective of Primary Care professionals



Abstract

We sought to understand the perspectives of Primary Health Care professionals regarding care transitions, as well as the work contexts that influence the continuity of such care. This is a qualitative research study, employing content analysis of interviews conducted with 15 health professionals from Primary Care units affiliated with a public hospital group in southern Brazil, within the framework of the Health Care Networks concept. The findings were organized into three thematic axes: communication and care transitions between health services; the role of Primary Health Care in the organization and coordination of care; and the relationship between users, families, and care networks. The study identified isolated practices of care transition between hospitals and Primary Care, revealing challenges ranging from limited referral options to other services to the lack of information regarding hospital admissions. Despite these challenges, Primary Health Care is highlighted as a potentially central coordinator of care within the organization of Health Care Networks, even though it faces difficulties in fulfilling this role. The study underscores the need to rethink care transitions between health services, aiming to improve the quality of care and promote better integration across the health system.

Keywords

transition of care,
continuity of patient care,
hospital discharge,
primary health care,
comprehensive health care

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