Transición del cuidado del adulto mayor internado para el hogar: implementación de buenas prácticas

Costa, Maria Fernanda Baeta Neves Alonso da; Sichieri, Karina; Poveda, Vanessa de Brito; Baptista, Cleide Maria Caetano; Aguado, Priscila Cantoni

Maria Fernanda Baeta Neves Alonso da Costa Corresponding author: Maria Fernanda Baeta Neves Alonso da Costa. E-mail: fernanda.baeta@ufsc.br

Universidade Federal de Santa Catarina. Florianópolis, Santa Catarina, Brazil.

https://orcid.org/0000-0002-2763-8050

Karina Sichieri

Universidade de São Paulo, Hospital Universitário. São Paulo, São Paulo, Brazil.

https://orcid.org/0000-0002-5074-4636

Vanessa de Brito Poveda

Universidade de São Paulo. São Paulo, São Paulo, Brazil.

https://orcid.org/0000-0002-5839-7253

Cleide Maria Caetano Baptista

Universidade de São Paulo, Hospital Universitário. São Paulo, São Paulo, Brazil.

https://orcid.org/0000-0002-3916-7700

Priscila Cantoni Aguado

Universidade de São Paulo, Hospital Universitário. São Paulo, São Paulo, Brazil.

https://orcid.org/0000-0003-4520-5969

Corresponding author: Maria Fernanda Baeta Neves Alonso da Costa. E-mail: fernanda.baeta@ufsc.br

EDITOR IN CHIEF: Dulce Barbosa

ASSOCIATE EDITOR: Fátima Helena Espírito Santo

Figuras (2)
Tablas (2)

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Figure 1
“Baseline Compliance with best practice for audit criteria” (%), São Paulo, Brazil, 2019

Criteria Legend

1 AII staff involved in transitional care have received education regarding transitional care from hospital to home for older people. (10 of 10 samples taken)

2 Patients/caregivers have received education regarding self-management interventions. (7 of 7 samples taken)

3 An individualized discharge plan has been documented for all patients transitioning from hospital to home. (7 of 7 samples taken)

4 Patients/caregivers have been involved in lhe discharge planning process. (7 of 7 samples taken)

5 Transitional care services have been coordinated between the hospital and community setting. (7 of 7 samples taken)

6 Patient care needs have been communicated between the hospital and community healthcare providers. (7 of 7 samples taken)

7 Post discharge follow-up has occurred. (7 of 7 samples taken)

8 A multifaceted, approach is used for transition ing older people from hospital to home (e.g. may include telephone follow-up, home-based exercise programs, patient-centered discharge instruction) (7 of 7 samples taken)

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Figure 2
Compliance with best practice audit criteria in follow-up auditing compared to baseline auditing (%), São Paulo, Brazil, 2019

Criteria Legend

1 All staff involved in transitional care have received education regarding transitional care from hospital to home for older people. (10 of 10 samples taken)

2 Patients/caregivers have received education regarding self-management interventions. (4 of 4 samples taken)

3 An individualized discharge plan has been documented for all patients transitioning from hospital to home. (4 of 4 samples taken)

4 Patients/caregivers have been invotved in the discharge planning process. (4 of 4 samples taken)

5 Transitional care services have been coordinated between the hospital and community setting. (4 of 4 samples taken)

6 Patient care needs have been communicated between the hospital and community healtthcare providers. (4 of 4 samples taken)

7 Post discharge fo/low-up has occurred. (4 of 4 samples taken)

8 A multifaceted, approach is used for transitioning older people from hospital to home (e.g. may include telephone follow-up, home-based exercise programs, patient-centered discharge instruction) (4 of 4 samples taken)

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Chart 1
Audit criteria, sample and approach for measuring compliance with best practices, São Paulo, Brazil, 2019

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Chart 2
Best practice implementation, São Paulo, Brazil, 2019

Audit criteria	Sample	Method used to measure (%) of compliance with best practices
1 - All staff involved in transitional care have received education regarding transitional care from hospital to home for older people. (10 of 10 samples taken)	Nurses Baseline audit: 10 Follow-up audit: 08	A questionnaire sent by Survey Monkey and Google Platform (form). Question: have you received training on transitional care in the past six months? It will be considered compliant if professional answers yes.
2 - Patients/caregivers have received education regarding self-management interventions. (7 of 7 samples taken)	Older people or caregivers/family members admitted to surgical clinic Baseline audit: 07 Follow-up audit: 04	Interview with older person, caregiver/family: Question: did you receive education about self-care at hospital discharge? Yes ( ) No ( ) The criterion will be considered fulfilled when older people, caregivers/family members answer affirmatively.
3 - An individualized discharge plan has been documented for all patients transitioning from hospital to home. (7 of 7 samples taken)	Medical records of older patients admitted to surgical clinic. Baseline audit: 07 Follow-up audit: 04	Was a discharge plan documented in nursing progress notes for hospital to home transition? Yes ( ) No ( ) The criterion will be considered fulfilled when discharge is recorded in the patient's medical record.
4 - Patients/caregivers have been involved in the discharge planning process. (7 of 7 samples taken)	Older people or caregiver/family member admitted to the surgical clinic. Baseline audit: 07 Follow-up audit: 04	Interview: Readiness for Hospital Discharge Scale adapted⁽¹⁵15 Siqueira TH, Vila VSC, Weiss ME. Cross-cultural adaptation of the instrument Readiness for Hospital Discharge Scale: adult form. Rev Bras Enferm. 2018;71(3):983-91. doi: 10.1590/0034-7167-2017-0241 https://doi.org/10.1590/0034-7167-2017-0... ⁾.
5 - Transitional care services have been coordinated between the hospital and community setting. (7 of 7 samples taken)	Patient system (Computerized System) Baseline audit: 07 Follow-up audit: 04	Check whether the return appointment was made at the HU-USP's outpatient clinic, after hospital discharge, in the hospital's computerized system. Yes ( ) No ( ) It will be considered compliant if there is in the scheduling system the schedule of the return with medical or nursing staff.
6 - Patient care needs have been communicated between the hospital and community healthcare providers. (7 of 7 samples taken)	Medical records of older patients admitted to surgical clinic. Baseline audit: 07 Follow-up audit: 04	The needs for patient care are documented in nursing progress notes at discharge. Yes ( ) No ( ) The criterion will be considered fulfilled if there is medical record registry.
7 - Post discharge follow-up has occurred. (7 of 7 samples taken)	Patient System (Computerized System) Baseline audit: 07 Follow-up audit: 04	Check in the computerized patient system if there was an outpatient nursing and/or physician return. Yes ( ) No ( ) The criterion will be considered fulfilled if a patient returned at the scheduled outpatient appointment.
8 - A multifaceted, approach is used for transitioning older people from hospital to home (e.g. may include telephone follow-up, home-based exercise programs, patient-centered discharge instruction) (7 of 7 samples taken).	Older people or caregivers/family members admitted to the surgical clinic Baseline audit: 07 Follow-up audit: 04	Interview with older people Question: did you receive guidance on general care, information leaflets, demonstration/participation in procedures, return to the outpatient clinic, medical prescription (medication use). Yes ( ) No ( ) The criterion will be considered fulfilled if older people or caregivers/family members answer yes

Barriers Expected	Strategies	Resources	Results
Absence of an individualized discharge plan for older people.	Identifying the health needs of older people based on Activities of daily living (ADL) and Instrumental Activities of Daily Living (IADL).	Questionnaire.	Discharge plan implemented and registration on care expanded; It was not achieved due to the project's implementation deadline.
Falta de conhecimento dos idosos, cuidadores/ familiares sobre os cuidados prescritos na alta hospitalar para casa.	Developing a folder with the main nursing care, in surgeries, which most occur with older people, in the surgical clinic: cholecystectomy, herniorrhaphy and orthopedic hip surgery.	- Paper sheet A4; - Photos from the internet and simulation dummy; - Computer; - Hospital communication service.	Development of three educational folders. However, they were not delivered to patients.
Absence of a complete record (health needs) in the medical record of older patients at hospital discharge.	Nurses' educational program on the main aspects to be registered at hospital discharge - guidelines provided, documents delivered, outpatient return, among others.	- Computer (Power Point); - Conversation round.	80% of the nurses trained.

[1] Corresponding author: Maria Fernanda Baeta Neves Alonso da Costa. E-mail: fernanda.baeta@ufsc.br

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Transición del cuidado del adulto mayor internado para el hogar: implementación de buenas prácticas

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