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      Liaison nurse activities at hospital discharge: a strategy for continuity of care* Translated title: Atividades das enfermeiras de ligação na alta hospitalar: uma estratégia para a continuidade do cuidado Translated title: Actividades de las enfermeras de enlace en el alta hospitalaria: una estrategia para la continuidad del cuidado

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          Abstract

          Objective

          to describe the activities developed by the liaison nurses for the continuity of care after hospital discharge.

          Method

          descriptive, qualitative study, based on the theoretical reference. Strength Based Care. The sample comprised 23 liaison nurses. The data was collected through a semi-structured questionnaire via Survey Monkey electronic platform and analyzed through the content analysis technique, with pre-defined categories.

          Results

          among the liaison nurses, nine (39.14%), between 35 and 44 years of age; 17 (73.91%) were female; 15 (65.22%) were working eleven years or more nurse and 11 (47.82%), were between six and ten years old as a liaison nurse. The professionals participate in the identification of the patients who need care after hospital discharge, coordinate the planning of the hospital discharge and transfer the patient’s information to an extra-hospital service.

          Conclusion

          the activities developed by the liaison nurses focus on the needs of the patient and the articulation with the extra-hospital services, and can be adapted to the Brazilian context as a strategy to minimize the discontinuity of care at the time of hospital discharge.

          Translated abstract

          Objetivo

          descrever as atividades desenvolvidas pelas enfermeiras de ligação para a continuidade do cuidado após a alta hospitalar.

          Método

          estudo descritivo, qualitativo, pautado no referencial teórico Cuidado Baseado nas Forças. A amostra compreendeu 23 enfermeiras de ligação. Os dados foram coletados por meio de um questionário semiestruturado via plataforma eletrônica Survey Monkey e analisados por meio da técnica de Análise de Conteúdo, com categorias pré-definidas.

          Resultados

          entre as enfermeiras de ligação, nove (39,14%) possuíam de 35 a 44 anos de idade; 17 (73,91%) eram do sexo feminino; 15 (65,22%) trabalhavam há onze ou mais anos como enfermeira e 11 (47,82%) atuavam de seis a dez anos como enfermeira de ligação. As profissionais participam da identificação dos pacientes que necessitam de cuidados pós-alta hospitalar, coordenam o planejamento da alta hospitalar e transferem as informações do paciente para um serviço extra-hospitalar.

          Conclusão

          as atividades desenvolvidas pelas enfermeiras de ligação centram-se nas necessidades do paciente e na articulação com os serviços extra-hospitalares e podem ser adaptadas ao contexto brasileiro como uma estratégia para minimizar a descontinuidade do cuidado por ocasião da alta hospitalar.

          Translated abstract

          Objetivo

          describir las actividades desarrolladas por las enfermeras de enlace para la continuidad del cuidado después del alta hospitalaria.

          Método

          estudio descriptivo, cualitativo, pautado en el referencial teórico Cuidado Basado en las Fuerzas. La muestra comprendió 23 enfermeras de enlace. Los datos fueron recolectados por medio de un cuestionario semiestructurado vía plataforma electrónica Survey Monkey y analizados por medio de la técnica de Análisis de Contenido, con categorías predefinidas.

          Resultados

          entre las enfermeras de enlace, nueve (39,14%), tenían 35 a 44 años de edad; 17 (73,91%), eran del sexo femenino; 15 (65,22%), trabajaban hace once o más años como enfermera y 11 (47,82%), actuaban de seis a diez años como enfermera de enlace. Las profesionales participan de la identificación de los pacientes que necesitan cuidados post-alta hospitalaria, coordinan la planificación del alta hospitalaria y transfieren las informaciones del paciente para un servicio extrahospitalario.

          Conclusión

          las actividades desarrolladas por las enfermeras de enlace se centran en las necesidades del paciente y en la articulación con los servicios extrahospitalarios, y pueden ser adaptadas al contexto brasileño como una estrategia para minimizar la discontinuidad del cuidado con ocasión del alta hospitalaria.

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          Most cited references21

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          Experienced continuity of care when patients see multiple clinicians: a qualitative metasummary.

          Continuity of care among different clinicians refers to consistent and coherent care management and good measures are needed. We conducted a metasummary of qualitative studies of patients' experience with care to identify measurable elements that recur over a variety of contexts and health conditions as the basis for a generic measure of management continuity. From an initial list of 514 potential studies (1997-2007), 33 met our criteria of using qualitative methods and exploring patients' experiences of health care from various clinicians over time. They were coded independently. Consensus meetings minimized conceptual overlap between codes. For patients, continuity of care is experienced as security and confidence rather than seamlessness. Coordination and information transfer between professionals are assumed until proven otherwise. Care plans help clinician coordination but are rarely discerned as such by patients. Knowing what to expect and having contingency plans provides security. Information transfer includes information given to the patient, especially to support an active role in giving and receiving information, monitoring, and self-management. Having a single trusted clinician who helps navigate the system and sees the patient as a partner undergirds the experience of continuity between clinicians. Some dimensions of continuity, such as coordination and communication among clinicians, are perceived and best assessed indirectly by patients through failures and gaps (discontinuity). Patients experience continuity directly through receiving information, having confidence and security on the care pathway, and having a relationship with a trusted clinician who anchors continuity.
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            Improving patient discharge and reducing hospital readmissions by using Intervention Mapping

            Background There is a growing impetus to reorganize the hospital discharge process to reduce avoidable readmissions and costs. The aim of this study was to provide insight into hospital discharge problems and underlying causes, and to give an overview of solutions that guide providers and policy-makers in improving hospital discharge. Methods The Intervention Mapping framework was used. First, a problem analysis studying the scale, causes, and consequences of ineffective hospital discharge was carried out. The analysis was based on primary data from 26 focus group interviews and 321 individual interviews with patients and relatives, and involved hospital and community care providers. Second, improvements in terms of intervention outcomes, performance objectives and change objectives were specified. Third, 220 experts were consulted and a systematic review of effective discharge interventions was carried out to select theory-based methods and practical strategies required to achieve change and better performance. Results Ineffective discharge is related to factors at the level of the individual care provider, the patient, the relationship between providers, and the organisational and technical support for care providers. Providers can reduce hospital readmission rates and adverse events by focusing on high-quality discharge information, well-coordinated care, and direct and timely communication with their counterpart colleagues. Patients, or their carers, should participate in the discharge process and be well aware of their health status and treatment. Assessment by hospital care providers whether discharge information is accurate and understood by patients and their community counterparts, are important examples of overcoming identified barriers to effective discharge. Discharge templates, medication reconciliation, a liaison nurse or pharmacist, regular site visits and teach-back are identified as effective and promising strategies to achieve the desired behavioural and environmental change. Conclusions This study provides a comprehensive guiding framework for providers and policy-makers to improve patient handover from hospital to primary care. Electronic supplementary material The online version of this article (doi:10.1186/1472-6963-14-389) contains supplementary material, which is available to authorized users.
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              Chronic disease in childhood and adolescence: continuity of care in the Health Care Network

              abstract OBJECTIVE To evaluate the continuity of care for children and adolescents with chronic diseases in the health care network. METHODS This qualitative study was conducted between February and October 2013 with 12 families, six health managers, and 14 health professionals from different health care services in a municipality of the state of Paraíba, Brazil, using focal groups, semi-structured interviews, and medical record consultation. The data were analyzed by triangulation and thematic analysis. RESULTS Two categories were created: “health care management” and “(dis)continuity of care.” We found gaps in the system, including poor data recording aimed to facilitate follow-up and guide the planning actions as well as sporadic and discoordinate services with a limited flow of information, which hinders follow-up over time. CONCLUSION Continuity of care in the health care network is limited and creates the need to develop strategies to improve these services.
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                Author and article information

                Journal
                Rev Lat Am Enfermagem
                Rev Lat Am Enfermagem
                rlae
                Revista Latino-Americana de Enfermagem
                Escola de Enfermagem de Ribeirão Preto / Universidade de São Paulo
                0104-1169
                1518-8345
                19 August 2019
                2019
                : 27
                : e3162
                Affiliations
                [1 ]Faculdade de Santa Catarina, Florianópolis, SC, Brasil.
                [2 ]Bolsista da Coordenação de Aperfeiçoamento de Pessoal de Nível Superior (CAPES), Brasil,
                [3]Programme des bourses des futurs leaders dans les Amériques 2016/2017, Canadá.
                [3 ]Universidade Federal do Paraná, Curitiba, PR, Brasil.
                [4 ]Université Laval, Faculté des Sciences Infirmières, Québec, QC, Canadá.
                Author notes
                Autor correspondente: Gisele knop Aued E-mail: giseleknop@ 123456gmail.com
                Author information
                http://orcid.org/0000-0001-5914-1105
                http://orcid.org/0000-0003-1321-8562
                http://orcid.org/0000-0003-3863-9080
                http://orcid.org/0000-0003-3170-5671
                Article
                00349
                10.1590/1518-8345.3069.3162
                6703099
                31432917
                833da05b-2208-4d77-bcbd-043c509eb9df
                Copyright © 2019 Revista Latino-Americana de Enfermagem

                This is an Open Access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

                History
                : 15 November 2018
                : 08 March 2019
                Page count
                Figures: 0, Tables: 0, Equations: 0, References: 22
                Categories
                Artigo Original

                nursing,continuity of patient care,patient discharge,transitional care,professional practice,health services administration,enfermagem,continuidade da assistência ao paciente,alta do paciente,cuidado transicional,prática profissional,administração dos serviços de saúde,enfermería,continuidad de la atención al paciente,alta del paciente,cuidado de transición,práctica profesional,administración de los servicios de salud

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