Estrategias de equipos de enfermería para el cuidado de personas mayores en la transición hospital-domicilio: revisión integradora

Editora Associada: Meiry Fernanda Pinto Okuno (https://orcid.org/0000-0003-4200-1186) Escola Paulista de Enfermagem, Universidade Federal de São Paulo, São Paulo, SP, Brasil

Conflitos de interesse: nada a declarar.

Autores/anos	Títulos	Bases de dados	Periódicos	Fatores de impacto
Sarzynski et al., 2019⁽⁷7. Sarzynski E, Ensberg M, Parkinson A, Fitzpatrick L, Houdeshell L, Given C, et al. Eliciting nurses' perspectives to improve health information exchange between hospital and home health care. Geriatr Nurs. 2019;40(3):277-83.⁾	Eliciting nurses’ perspectives to improve health information exchange between hospital and home health care	CINAHL	Geriatr. Nurs.	2,525
Kim et al., 2020⁽⁸8. Kim YS, Lee J, Moon Y, Kim HJ, Shin J, Park JM, et al. Development of a senior-specific, citizen-oriented healthcare service system in South Korea based on the Canadian 48/6 model of care. BMC Geriatr. 2020;20(1):32.⁾	Development of a senior-specific, citizen-oriented healthcare service system in South Korea based on the Canadian 48/6 model of care	CINAHL	BMC Geriatrics	4,070
Cheen et al., 2017⁽⁹9. Cheen MH, Goon CP, Ong WC, Lim PS, Wan CN, Leong MY, et al. Evaluation of a care transition program with pharmacist-provided home-based medication review for elderly Singaporeans at high risk of readmissions. Int J Qual Health Care. 2017;29(2):200-5.⁾	Evaluation of a care transition program with pharmacist-provided home-based medication review for elderly Singaporeans at high risk of readmissions	CINAHL	Int. J. Qual. Health Care	2,257
Hansen et al., 2021⁽¹⁰10. Hansen TK, Pedersen LH, Shahla S, Damsgaard EM, Bruun JM, Gregersen M. Effects of a new early municipality-based versus a geriatric team-based transitional care intervention on readmission and mortality among frail older patients - a randomised controlled trial. Arch Gerontol Geriatr. 2021;97:104511.⁾	Effects of a new early municipality-based versus a geriatric team-based transitional care intervention on readmission and mortality among frail older patients - a randomised controlled trial	Web Of Science	Arch. Gerontol. Geriatr.	4,163
Wang et al., 2019⁽¹¹11. Wang YC, Lu YP, Wang JH, Liang CK, Choul MY, Lin YT. The Effectiveness of a Timely Discharge Plan in Older Adults: A Prospective Hospital-Based Cohort Study in Southern Taiwan. Aging Med Healthcare. 2019;10(3):104-8.⁾	The Effectiveness of a Timely Discharge Plan in Older Adults: A Prospective Hospital-Based Cohort Study in Southern Taiwan	Web Of Science	Aging Med. Healthcare	0,26
Allen et al., 2020⁽¹²12. Allen J, Hutchinson AM, Brown R, Livingston PM. Communication and Coordination Processes Supporting Integrated Transitional Care: Australian Healthcare Practitioners' Perspectives. Int J Integr Care. 2020;20(2):1-10.⁾	Communication and Coordination Processes Supporting Integrated Transitional Care: Australian Healthcare Practitioners’ Perspectives	Pubmed	Int. J. Integr. Care	2,913
Costa et al., 2019⁽¹³13. Costa MF, Andrade SR, Soares CF, Pérez EI, Tomás SC, Bernardino E. The continuity of hospital nursing care for Primary Health Care in Spain. Rev Esc Enferm USP. 2019;53:e03477.⁾	The continuity of hospital nursing care for Primary Health Care in Spain	SCOPUS	Rev. Esc. Enferm. USP	1,123
Verweij et al., 2018⁽¹⁴14. Verweij L, Jepma P, Buurman BM, Latour CH, Engelbert RH, Ter Riet G, et al. The cardiac care bridge program: design of a randomized trial of nurse-coordinated transitional care in older hospitalized cardiac patients at high risk of readmission and mortality. BMC Health Serv Res. 2018;18(1):508.⁾	The cardiac care bridge program: design of a randomized trial of nurse-coordinated transitional care in older hospitalized cardiac patients at high risk of readmission and mortality	Portal Regional da BVS	BMC Health Serv. Res.	2,908
Arbaje et al., 2010⁽¹⁵15. Arbaje AI, Maron DD, Yu Q, Wendel VI, Tanner E, Boult C, et al. The geriatric floating interdisciplinary transition team. J Am Geriatr Soc. 2010;58(2):364-70.⁾	The Geriatric Floating Interdisciplinary Transition Team	Portal Regional da BVS	J. Am. Geriatr. Soc.	7,538
Buurman et al., 2016⁽¹⁶16. Buurman BM, Parlevliet JL, Allore HG, Blok W, van Deelen BA, Moll van Charante EP, et al. Comprehensive Geriatric Assessment and Transitional Care in Acutely Hospitalized Patients: The Transitional Care Bridge Randomized Clinical Trial. JAMA Intern Med. 2016;176(3):302-9.⁾	Comprehensive Geriatric Assessment and Transitional Care in Acutely Hospitalized Patients: The Transitional Care Bridge Randomized Clinical Trial	Portal Regional da BVS	JAMA Intern. Med.	44,424
Chareh et al., 202⁽¹⁷17. Chareh N, Rappl A, Rimmele M, Wingenfeld K, Freiberger E, Sieber CC, et al. Does a 12-Month Transitional Care Model Intervention by Geriatric-Experienced Care Professionals Improve Nutritional Status of Older Patients after Hospital Discharge? A Randomized Controlled Trial. Nutrients. 2021;13(9):3023.⁾	Does a 12-Month Transitional Care Model Intervention by Geriatric-Experienced Care Professionals Improve Nutritional Status of Older Patients after Hospital Discharge? A Randomized Controlled Trial	CINAHL	Nutrients	6,706
Stauffer et al., 2011⁽¹⁸18. Stauffer BD, Fullerton C, Fleming N, Ogola G, Herrin J, Stafford PM, et al. Effectiveness and cost of a transitional care program for heart failure: a prospective study with concurrent controls. Arch Intern Med. 2011;171(14):1238-43.⁾	Effectiveness and Cost of a Transitional Care Program for Heart Failure A Prospective Study With Concurrent Controls	CINAHL	JAMA Intern. Med.	44,424
Jepma et al., 2021⁽¹⁹19. Jepma P, Latour CH, Ten Barge IH, Verweij L, Peters RJ, Scholte Op Reimer WJM, et al. Experiences of frail older cardiac patients with a nurse-coordinated transitional care intervention - a qualitative study. BMC Health Serv Res. 2021;21(1):786.⁾	Experiences of frail older cardiac patients with a nurse-coordinated transitional care intervention - a qualitative study	CINAHL	BMC Health Serv. Res.	2,908
Finlayson et al., 2018⁽²⁰20. Finlayson K, Chang AM, Courtney MD, Edwards HE, Parker AW, Hamilton K, et al. Transitional care interventions reduce unplanned hospital readmissions in high-risk older adults. BMC Health Serv Res. 2018;18(1):956.⁾	Transitional care interventions reduce unplanned hospital readmissions in high-risk older adults	CINAHL	BMC Health Serv. Res	2,908

Autores/anos	Países Tipos de estudo	Participantes	Estratégias da equipe de enfermagem para os cuidados de transição hospital-domicílio
Sarzynski et al., 2019⁽⁷7. Sarzynski E, Ensberg M, Parkinson A, Fitzpatrick L, Houdeshell L, Given C, et al. Eliciting nurses' perspectives to improve health information exchange between hospital and home health care. Geriatr Nurs. 2019;40(3):277-83.⁾	EUA, Mid-Michigan Estudo qualitativo; grupo focal	Enfermeiros de assistência domiciliar (n=19)	Implementação de protocolos para ajuste medicamentoso antes da primeira consulta de acompanhamento ambulatorial. Simplificação do regime medicamentoso. Orientação em saúde adotando materiais com linguagem simples; Triagem dos determinantes sociais de saúde (financeiro, transporte e ambiente doméstico); Identificação do cuidador e suas informações de contato
Kim et al., 2020⁽⁸8. Kim YS, Lee J, Moon Y, Kim HJ, Shin J, Park JM, et al. Development of a senior-specific, citizen-oriented healthcare service system in South Korea based on the Canadian 48/6 model of care. BMC Geriatr. 2020;20(1):32.⁾	Coréia do Sul Entrevista com grupo focal e consulta a especialistas.	Enfermeiros e médicos	Triagem e avaliação do geriatric screening for care-10, abrangendo dez domínios: Comprometimento cognitivo, depressão, delírio, polifarmácia, declínio funcional, disfagia, desnutrição, incontinências urinária e fecal, dor.
Cheen et al., 2017⁽⁹9. Cheen MH, Goon CP, Ong WC, Lim PS, Wan CN, Leong MY, et al. Evaluation of a care transition program with pharmacist-provided home-based medication review for elderly Singaporeans at high risk of readmissions. Int J Qual Health Care. 2017;29(2):200-5.⁾	Cingapura Estudo observacional retrospectivo	Enfermeiros coordenadores de cuidados e farmacêuticos	Visita domiciliar de farmacêuticos e coordenadores de atendimento e/ou cuidado (enfermeiros) para dar informações sobre o gerenciamento de doenças, revisão abrangente e aconselhamento medicamentoso.
Hansen et al., 2021⁽¹⁰10. Hansen TK, Pedersen LH, Shahla S, Damsgaard EM, Bruun JM, Gregersen M. Effects of a new early municipality-based versus a geriatric team-based transitional care intervention on readmission and mortality among frail older patients - a randomised controlled trial. Arch Gerontol Geriatr. 2021;97:104511.⁾	Dinamarca Estudo controlado randomizado	Enfermeiras apoiadas por um clínico geral	Avaliação geriátrica ampla baseada nos 14 componentes da enfermagem conforme a teoria de Virgínia Henderson. Revisão da lista de prescrição.
Wang et al., 2019⁽¹¹11. Wang YC, Lu YP, Wang JH, Liang CK, Choul MY, Lin YT. The Effectiveness of a Timely Discharge Plan in Older Adults: A Prospective Hospital-Based Cohort Study in Southern Taiwan. Aging Med Healthcare. 2019;10(3):104-8.⁾	Tailândia Estudo prospectivo de caso-controle	Enfermeiras especialistas em alta, geriatras e fisioterapeuta	Avaliação geriátrica abrangente do paciente antes da alta hospitalar por enfermeiras especialistas em alta. Promoção dos cuidados de longo prazo no domicílio, comunicando aos prestadores antes da alta do paciente.
Allen et al., 2020⁽¹²12. Allen J, Hutchinson AM, Brown R, Livingston PM. Communication and Coordination Processes Supporting Integrated Transitional Care: Australian Healthcare Practitioners' Perspectives. Int J Integr Care. 2020;20(2):1-10.⁾	Austrália Estudo qualitativo	Equipe multi, majoritariamente composto por enfermeiras (n=25)	Discussão entre equipes multiprofissionais para transição rápida e segura. Elaboração de plano de alta hospitalar para o ambiente domiciliar; Envolvimento de pacientes e cuidadores nos cuidados de transição.
Costa et al., 2019⁽¹³13. Costa MF, Andrade SR, Soares CF, Pérez EI, Tomás SC, Bernardino E. The continuity of hospital nursing care for Primary Health Care in Spain. Rev Esc Enferm USP. 2019;53:e03477.⁾	Espanha Estudo qualitativo	Enfermeiras de ligação hospitalar (n=19)	Avaliação e verificação da necessidade de cuidado através de consulta à equipe multiprofissional e reunião interdisciplinar. Avaliação dos pacientes antes da alta hospitalar, incluindo os domínios físico, cognitivo, mental, social e emocional; Uso de instrumentos como Gordon, Barthel, Pfeiffer e Zarit para avaliação de cuidados complexos (feridas), estado nutricional e informações sobre o cuidador. Avaliação social; Aplicação de questionário de risco social (TIRS).
Verweij et al., 2018⁽¹⁴14. Verweij L, Jepma P, Buurman BM, Latour CH, Engelbert RH, Ter Riet G, et al. The cardiac care bridge program: design of a randomized trial of nurse-coordinated transitional care in older hospitalized cardiac patients at high risk of readmission and mortality. BMC Health Serv Res. 2018;18(1):508.⁾	Holanda Estudo multicêntrico simples-cego com randomização	Enfermeiras especialistas em cardiologia, geriatria e cuidados comunitários e um fisioterapeuta	Planejamento da alta e elaboração de planos de cuidados baseados na avaliação geriátrica abrangente, condição de saúde atual e prescrição de medicamentos. Emprego de fisioterapeuta da atenção primária para reabilitação cardíaca no domicílio antes da alta hospitalar. Verificação de medicamentos em uso no domicílio e prescritos na alta hospitalar.
Arbaje et al., 2010⁽¹⁵15. Arbaje AI, Maron DD, Yu Q, Wendel VI, Tanner E, Boult C, et al. The geriatric floating interdisciplinary transition team. J Am Geriatr Soc. 2010;58(2):364-70.⁾	EUA, Johns Hopkins Estudo de coorte	Enfermeira geriátrica e um médico geriatra	Educação de idosos e cuidadores sobre medicamentos e habilidades de autogerenciamento antes da alta hospitalar Orientações realizadas 48 h após a alta, via fax sobre a descrição da hospitalização e mudanças no regime medicamentoso. Uso de telefonemas para os pacientes ou cuidadores revisando os sintomas, uso de medicamentos, habilidades de autogerenciamento.
Buurman et al., 2016⁽¹⁶16. Buurman BM, Parlevliet JL, Allore HG, Blok W, van Deelen BA, Moll van Charante EP, et al. Comprehensive Geriatric Assessment and Transitional Care in Acutely Hospitalized Patients: The Transitional Care Bridge Randomized Clinical Trial. JAMA Intern Med. 2016;176(3):302-9.⁾	Holanda Ensaio clínico duplo-cego, multicêntrico e randomizado	Enfermeira de cuidados comunitários	Avaliação geriátrica abrangente Discussão sobre os planos de cuidados, necessidades e tratamentos antes da alta, envolvendo enfermeiras, idosos e cuidadores informais Avaliação das necessidades dos idosos, reconciliação medicamentosa e esclarecimento de dúvidas após alta hospitalar.
Chareh et al., 202⁽¹⁷17. Chareh N, Rappl A, Rimmele M, Wingenfeld K, Freiberger E, Sieber CC, et al. Does a 12-Month Transitional Care Model Intervention by Geriatric-Experienced Care Professionals Improve Nutritional Status of Older Patients after Hospital Discharge? A Randomized Controlled Trial. Nutrients. 2021;13(9):3023.⁾	Alemanha Análise secundária de ensaio controlado randomizado não-cego	Enfermeiros (n=5), um gerente de caso e um terapeuta ocupacional	Desenvolvimento de planos de cuidado individualizado abrangente envolvendo profissionais da saúde, idosos e familiares. Avaliação de problemas nutricionais, funcionalidade, cognição, gerenciamento medicamentoso, condições do ambiente domiciliar, dificuldades nas Atividades Básicas de Vida Diárias e autocuidado dos idosos no domicílio
Stauffer et al., 2011⁽¹⁸18. Stauffer BD, Fullerton C, Fleming N, Ogola G, Herrin J, Stafford PM, et al. Effectiveness and cost of a transitional care program for heart failure: a prospective study with concurrent controls. Arch Intern Med. 2011;171(14):1238-43.⁾	EUA, Dallas-Fort Worth, norte do Texas Estudo piloto	Enfermeiras de prática avançada	Educação do idoso e cuidadores 72 h após alta para estabelecer metas, orientá-los sobre a gravidade da insuficiência cardíaca, revisar o comportamento e habilidades gerais em saúde.
Jepma et al., 2021⁽¹⁹19. Jepma P, Latour CH, Ten Barge IH, Verweij L, Peters RJ, Scholte Op Reimer WJM, et al. Experiences of frail older cardiac patients with a nurse-coordinated transitional care intervention - a qualitative study. BMC Health Serv Res. 2021;21(1):786.⁾	Holanda Ensaio multicêntrico randomizado controlado	Programa liderado por enfermeiras	Avaliação geriátrica abrangente para identificar condições geriátricas e desenvolver um plano de cuidados integrado. Entrega do plano de cuidados integrados ao idoso para o preparo da alta. Visitas domiciliares para reconciliação medicamentosa, sinalização precoce de agravamento, complicações de saúde e avaliação do plano de cuidados.
Finlayson et al., 2018⁽²⁰20. Finlayson K, Chang AM, Courtney MD, Edwards HE, Parker AW, Hamilton K, et al. Transitional care interventions reduce unplanned hospital readmissions in high-risk older adults. BMC Health Serv Res. 2018;18(1):956.⁾	Austrália Ensaio controlado randomizado	Enfermeiras e um fisiologista do exercício	Visita domiciliar 48 h após a alta para avaliar: 1. Apoio suficiente do cuidador para com o idoso 2. Segurança do ambiente doméstico, 3. Acesso a medicamentos e curativos, 4. Compreensão do regime medicamentoso e do tratamento 5. Reforço do programa de exercícios e uso do pedômetro em casa 6. Aconselhamento e apoio ao cuidador

Categorias

Estudos que abordaram o conteúdo

Estratégias de cuidado desempenhadas pela enfermagem no ambiente hospitalar para a transição do cuidado ao domicílio.

⁽ ⁸8. Kim YS, Lee J, Moon Y, Kim HJ, Shin J, Park JM, et al. Development of a senior-specific, citizen-oriented healthcare service system in South Korea based on the Canadian 48/6 model of care. BMC Geriatr. 2020;20(1):32.

9. Cheen MH, Goon CP, Ong WC, Lim PS, Wan CN, Leong MY, et al. Evaluation of a care transition program with pharmacist-provided home-based medication review for elderly Singaporeans at high risk of readmissions. Int J Qual Health Care. 2017;29(2):200-5. ^- ¹⁰10. Hansen TK, Pedersen LH, Shahla S, Damsgaard EM, Bruun JM, Gregersen M. Effects of a new early municipality-based versus a geriatric team-based transitional care intervention on readmission and mortality among frail older patients - a randomised controlled trial. Arch Gerontol Geriatr. 2021;97:104511. ^- ¹¹11. Wang YC, Lu YP, Wang JH, Liang CK, Choul MY, Lin YT. The Effectiveness of a Timely Discharge Plan in Older Adults: A Prospective Hospital-Based Cohort Study in Southern Taiwan. Aging Med Healthcare. 2019;10(3):104-8. ^- ¹²12. Allen J, Hutchinson AM, Brown R, Livingston PM. Communication and Coordination Processes Supporting Integrated Transitional Care: Australian Healthcare Practitioners' Perspectives. Int J Integr Care. 2020;20(2):1-10. ^- ¹³13. Costa MF, Andrade SR, Soares CF, Pérez EI, Tomás SC, Bernardino E. The continuity of hospital nursing care for Primary Health Care in Spain. Rev Esc Enferm USP. 2019;53:e03477. ^- ¹⁴14. Verweij L, Jepma P, Buurman BM, Latour CH, Engelbert RH, Ter Riet G, et al. The cardiac care bridge program: design of a randomized trial of nurse-coordinated transitional care in older hospitalized cardiac patients at high risk of readmission and mortality. BMC Health Serv Res. 2018;18(1):508. ^- ¹⁵15. Arbaje AI, Maron DD, Yu Q, Wendel VI, Tanner E, Boult C, et al. The geriatric floating interdisciplinary transition team. J Am Geriatr Soc. 2010;58(2):364-70. ^- ¹⁶16. Buurman BM, Parlevliet JL, Allore HG, Blok W, van Deelen BA, Moll van Charante EP, et al. Comprehensive Geriatric Assessment and Transitional Care in Acutely Hospitalized Patients: The Transitional Care Bridge Randomized Clinical Trial. JAMA Intern Med. 2016;176(3):302-9. ^- ¹⁷17. Chareh N, Rappl A, Rimmele M, Wingenfeld K, Freiberger E, Sieber CC, et al. Does a 12-Month Transitional Care Model Intervention by Geriatric-Experienced Care Professionals Improve Nutritional Status of Older Patients after Hospital Discharge? A Randomized Controlled Trial. Nutrients. 2021;13(9):3023. ^- ¹⁸18. Stauffer BD, Fullerton C, Fleming N, Ogola G, Herrin J, Stafford PM, et al. Effectiveness and cost of a transitional care program for heart failure: a prospective study with concurrent controls. Arch Intern Med. 2011;171(14):1238-43. ^- ¹⁹19. Jepma P, Latour CH, Ten Barge IH, Verweij L, Peters RJ, Scholte Op Reimer WJM, et al. Experiences of frail older cardiac patients with a nurse-coordinated transitional care intervention - a qualitative study. BMC Health Serv Res. 2021;21(1):786. ⁾

Estratégias desempenhadas pela enfermagem para continuidade do cuidado na comunidade.

⁽ ⁷7. Sarzynski E, Ensberg M, Parkinson A, Fitzpatrick L, Houdeshell L, Given C, et al. Eliciting nurses' perspectives to improve health information exchange between hospital and home health care. Geriatr Nurs. 2019;40(3):277-83. ^- ⁸8. Kim YS, Lee J, Moon Y, Kim HJ, Shin J, Park JM, et al. Development of a senior-specific, citizen-oriented healthcare service system in South Korea based on the Canadian 48/6 model of care. BMC Geriatr. 2020;20(1):32. ^- ⁹9. Cheen MH, Goon CP, Ong WC, Lim PS, Wan CN, Leong MY, et al. Evaluation of a care transition program with pharmacist-provided home-based medication review for elderly Singaporeans at high risk of readmissions. Int J Qual Health Care. 2017;29(2):200-5. ^- ¹⁰10. Hansen TK, Pedersen LH, Shahla S, Damsgaard EM, Bruun JM, Gregersen M. Effects of a new early municipality-based versus a geriatric team-based transitional care intervention on readmission and mortality among frail older patients - a randomised controlled trial. Arch Gerontol Geriatr. 2021;97:104511.

11. Wang YC, Lu YP, Wang JH, Liang CK, Choul MY, Lin YT. The Effectiveness of a Timely Discharge Plan in Older Adults: A Prospective Hospital-Based Cohort Study in Southern Taiwan. Aging Med Healthcare. 2019;10(3):104-8. ^- ¹²12. Allen J, Hutchinson AM, Brown R, Livingston PM. Communication and Coordination Processes Supporting Integrated Transitional Care: Australian Healthcare Practitioners' Perspectives. Int J Integr Care. 2020;20(2):1-10. ^- ¹³13. Costa MF, Andrade SR, Soares CF, Pérez EI, Tomás SC, Bernardino E. The continuity of hospital nursing care for Primary Health Care in Spain. Rev Esc Enferm USP. 2019;53:e03477. ^- ¹⁴14. Verweij L, Jepma P, Buurman BM, Latour CH, Engelbert RH, Ter Riet G, et al. The cardiac care bridge program: design of a randomized trial of nurse-coordinated transitional care in older hospitalized cardiac patients at high risk of readmission and mortality. BMC Health Serv Res. 2018;18(1):508. ^- ¹⁵15. Arbaje AI, Maron DD, Yu Q, Wendel VI, Tanner E, Boult C, et al. The geriatric floating interdisciplinary transition team. J Am Geriatr Soc. 2010;58(2):364-70. ^- ¹⁶16. Buurman BM, Parlevliet JL, Allore HG, Blok W, van Deelen BA, Moll van Charante EP, et al. Comprehensive Geriatric Assessment and Transitional Care in Acutely Hospitalized Patients: The Transitional Care Bridge Randomized Clinical Trial. JAMA Intern Med. 2016;176(3):302-9. ^- ¹⁷17. Chareh N, Rappl A, Rimmele M, Wingenfeld K, Freiberger E, Sieber CC, et al. Does a 12-Month Transitional Care Model Intervention by Geriatric-Experienced Care Professionals Improve Nutritional Status of Older Patients after Hospital Discharge? A Randomized Controlled Trial. Nutrients. 2021;13(9):3023. ^- ¹⁸18. Stauffer BD, Fullerton C, Fleming N, Ogola G, Herrin J, Stafford PM, et al. Effectiveness and cost of a transitional care program for heart failure: a prospective study with concurrent controls. Arch Intern Med. 2011;171(14):1238-43. ^- ¹⁹19. Jepma P, Latour CH, Ten Barge IH, Verweij L, Peters RJ, Scholte Op Reimer WJM, et al. Experiences of frail older cardiac patients with a nurse-coordinated transitional care intervention - a qualitative study. BMC Health Serv Res. 2021;21(1):786. ^- ²⁰20. Finlayson K, Chang AM, Courtney MD, Edwards HE, Parker AW, Hamilton K, et al. Transitional care interventions reduce unplanned hospital readmissions in high-risk older adults. BMC Health Serv Res. 2018;18(1):956. ⁾

[1] Autor correspondente: Jessica Lane Pereira Santos E-mail: jessicalane84@gmail.com

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Estrategias de equipos de enfermería para el cuidado de personas mayores en la transición hospital-domicilio: revisión integradora

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