TRANSICIÓN DE LA ATENCIÓN EN EL ALTA HOSPITALARIA PARA PACIENTES ADULTOS: REVISIÓN INTEGRATIVA DE LA LITERATURA

Gheno, Jociele; Weis, Alísia Helena

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Brasil

Texto & Contexto - Enfermagem

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Brasil

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Sumário

Literature Review • Texto contexto - enferm. 30 • 2021 • https://doi.org/10.1590/1980-265X-TCE-2021-0030 copiar

TRANSICIÓN DE LA ATENCIÓN EN EL ALTA HOSPITALARIA PARA PACIENTES ADULTOS: REVISIÓN INTEGRATIVA DE LA LITERATURA

Autoría SCIMAGO INSTITUTIONS RANKINGS

RESUMEN

Objetivo:

sintetizar y analizar la producción científica sobre la transición de la atención al alta hospitalaria del paciente adulto.

Método:

una revisión integradora, realizada de mayo a julio de 2020, en cuatro bases de datos relevantes en el área de la salud: Public Medline (PubMed); Scientific Electronic Library Online (SciELO); Scopus y Biblioteca Virtual en Salud (BVS). El análisis de los resultados fue descriptivo y organizado en categorías temáticas que surgieron de acuerdo a la similitud de los contenidos extraídos de los artículos.

Resultados:

46 artículos de revistas nacionales e internacionales cumplieron los criterios de inclusión, con predominio de estudios descriptivos / no experimentales o con abordaje cualitativo. Se identificaron cinco categorías: Proceso de alta hospitalaria y posterior al alta; Continuidad de la atención posterior al alta; Beneficios de la transición de la atención״; El papel de la enfermera en la transición de la atención y Experiencias de los pacientes en la transición de la atención. El alta hospitalaria y las transiciones de la atención son procesos interconectados, ya que las transiciones califican el proceso de deshospitalización. Se deben adoptar diferentes estrategias para la continuidad de la atención, ya que ofrecen mayor seguridad al paciente. Los estudios han demostrado que los enfermeros juegan un papel fundamental en las transiciones y, en Brasil, esta actividad aún necesita ganar más espacio. La reducción de los reingresos, la mortalidad, los costos hospitalarios y la satisfacción del paciente son beneficios de las transiciones.

Conclusión:

la transición de la atención surge como una estrategia efectiva para calificar la atención brindada al paciente que se encuentra en proceso de deshospitalización. Señala la necesidad de integración entre la red de atención y ayuda a los servicios a tomar decisiones sobre la continuidad de la atención al alta.

DESCRIPTORES:
Atención de transición; Alta del paciente; Continuidad de la atención al paciente; Manejo de la salud; Enfermería

Authors	Year	NE^*	Objective	Outcome/Conclusion
Soto GE, et al. 1717. Soto GE, Huenefeldt EA, Hengst MN, Reimer AJ, Samuel SK, Samuel SK, et al. Implementation and impact analysis of a transitional care pathway for patients presenting to the emergency department with cardiac-related complaints. BMC Health Serv Res [Internet]. 2018 [cited 2020 June 20]; 18:672. Available from: https://doi.org/10.1186/s12913-018-3482-2 https://doi.org/10.1186/s12913-018-3482-...	2018	4	Evaluate the impact of implementing a structured transition care pathway involving low-risk cardiac patients at emergency room discharges, revisits and admissions in 30 days.	Increased number of discharges in the emergency room of cardiac patients, cost savings and lower risk of returning to the emergency room among patients receiving transitional care.
Garnier A, et al.1818. Garnier A, Rouiller N, Gachoud D, Nachar C, Voirol P, Griesser AC, et al. Effectiveness of a transition plan at discharge of patients hospitalized with heart failure: A before-andafter study. ESC Hear Fail [Internet]. 2018 [cited 2020 June 22];5(4):657-67. Available from: https://doi.org/10.1002/ehf2.12295 https://doi.org/10.1002/ehf2.12295...	2018	4	Evaluate the effectiveness of a multidisciplinary transition plan to reduce early readmission among patients with heart failure.	The care transition plan showed no benefits in readmission rates.
Cao XY, et al.1919. Cao XY, Tian L, Chen L, Jiang XL. Effects of a hospital-community partnership transitional program in patients with coronary heart disease in Chengdu, China: A randomized controlled trial. Japan J Nurs Sci [Internet]. 2017 [cited 2020 June 20];14(4):320-31. Available from: https://doi.org/10.1111/jjns.12160 . https://doi.org/10.1111/jjns.12160...	2017	2	Evaluate the effects of a transition program of partnership between hospital and community among patients with coronary heart disease.	Care transition program achieved significant results in reducing readmission rates, improving the quality of the transition and adhering to the use of medications.
Wong FKY, et al.2020. Wong FKY, Ng AYM, Lee PH, Lam PT, Ng JSC, Ng NHY, et al. Effects of a transitional palliative care model on patients with end-stage heart failure: A randomised controlled trial. Heart [Internet]. 2016 [cited 2020 May 24];102(14):1100-8. Available from: https://doi.org/10.1136/heartjnl-2015-308638 . https://doi.org/10.1136/heartjnl-2015-30...	2016	2	To analyze the effects of transitional palliative care in patients with end-stage heart failure (HF) after hospital discharge.	Reduction of readmissions and improvement of quality of life among hf patients of the post-discharge palliative program.
Hamar B, et al. 2121. Hamar B, Rula EY, Wells AR, Coberley C, Pope JE, Varga D. Impact of a scalable care transitions program for readmission avoidance. Am J Manag Care [Internet]. 2016 [cited 2020 June 20];22(1):28-34. Available from: https://www.ajmc.com/view/impact-of-a-scalable-care-transitions-program-for-readmission-avoidance https://www.ajmc.com/view/impact-of-a-sc...	2016	4	Evaluate the Care Transition Solution (CTS) as a means of improving quality by reducing avoidable hospital readmissions among patients with readable-sensitive conditions subject to the penalties imposed by the Affordable Care Act.	The implementation of a transition care program has significantly reduced the readmissions of patients diagnosed with COPD, HF, infarction or pneumonia.
Aboumatar H, et al.2222. Aboumatar H, Naqibuddin M, Chung S, Chaudhry H, Kim SW, Saunders J, et al. Effect of a Program combining transitional care and long-term self-management support on outcomes of hospitalized patients with chronic obstructive pulmonary disease: a randomized clinical trial. JAMA [Internet]. 2018 [cited 2020 June 10];320(22):2335-43. Available from: https://doi.org/10.1001/jama.2018.17933 . https://doi.org/10.1001/jama.2018.17933...	2018	2	Evaluate a program that combined transition and long-term self-management support for patients hospitalized due to COPD and their family caregivers.	The program resulted significantly in fewer hospitalizations, emergency room visits and improved health quality.
Pauly MV, et al.2323. Pauly MV, Hirschman KB, Hanlon AL, Huang L, Bowles KH, Bradway C, et al. Cost impact of the transitional care model for hospitalized cognitively impaired older adults. J Comp Eff Res [Internet]. 2018 [cited 2020 June 21];7(9):913-22. Available from: https://doi.org/10.2217/cer-2018-0040 https://doi.org/10.2217/cer-2018-0040...	2018	4	Compare the costs of post-acute care of three care management interventions.	The care transition model can reduce the amount of other post-acute care and the total cost compared to other care models.
Reidt SL, et al.2424. Reidt SL, Holtan HS, Larson TA, Thompson B, Kerzner LJ, Salvatore TM, et al. Interprofessional collaboration to improve discharge from skilled nursing facility to home: preliminary data on postdischarge hospitalizations and emergency department visits. J Am Geriatr Soc [Internet]. 2016 [cited 2020 June 20];64(9):1895-9. Available from: https://doi.org/10.1111/jgs.14258 . https://doi.org/10.1111/jgs.14258...	2016	4	Describe the interprofessional collaborative practice model and compare the results between individuals who received care according to this model and those who received usual care.	The interprofessional collaborative practice model is performed by a geriatric, a nurse and a pharmacist. The actions of this model can decrease hospitalizations and visits to the emergency room within 30 days after discharge.
Neighbour BM, et al.2525. Buurman BM, Parlevliet JL, Allore HG, Blok W, Van Deelen BAJ, Moll Van Charante EP, et al. Comprehensive geriatric assessment and transitional care in acutely hospitalized patients the transitional care bridge randomized clinical trial. JAMA [Internet]. 2016 [cited 2020 Jul 18];176(3):302-9. Available from: https://doi.org/10.1001/jamainternmed.2015.8042 . https://doi.org/10.1001/jamainternmed.20...	2016	2	Testing whether a systematic comprehensive geriatric assessment (CGA) intervention followed by the care transition program improved activities of daily living (ADLs) compared to isolated systematic CGA.	The intervention showed no effect on ADLs compared to the isolated systemic CGA. But there was a significant reduction in mortality in one month and six months after admission.
Low LL, et al.2626. Low LL, Tan SY, Ng MJM, Tay WY, Ng LB, Balasubramaniam K, et al. Applying the integrated practice unit concept to a modified virtual ward model of care for patients at highest risk of readmission: A randomized controlled trial. PLoS One [Internet]. 2017 [cited 2020 Jul 15];12(1):e0168757. Available from: https://doi.org/10.1371/journal.pone.0168757 . https://doi.org/10.1371/journal.pone.016...	2017	2	Assess whether the new application of the integrated practice unit concept and the virtual ward model can reduce the readmission of patients at higher risk of readmission.	The application of the concept of a practice unit integrated into the virtual ward program resulted in reduced readmissions in patients at higher risk of readmission. Patients were discharged and post-discharge follow-up with calls or visits.
Eggen AC, et al.2727. Eggen AC, Jalving M, Bosma I, Veenhuis DJ, Bosscher LJ, Geerling JI, et al. A methodology to systematically analyze the hospital discharge of terminally ill patients. Med (United States) [Internet]. 2018 [cited 2020 Jul 15];97(46): e12953. Available from: https://doi.org/10.1097/MD.0000000000012953 https://doi.org/10.1097/MD.0000000000012...	2018	4	Provide an appropriate method to systematically evaluate the procedure of hospital discharge of terminal patients that can be implemented in any hospital to analyze the process of hospital discharge.	To improve transitional care, the discharge procedure should include well-structured written and oral transfer, with more emphasis on prior care planning and actual use of medication.
Couturier B, et al.2828. Couturier B, Carrat F, Hejblum G. A systematic review on the effect of the organisation of hospital discharge on patient health outcomes. BMJ Open [Internet]. 2016 [cited 2020 Jul 15];6(12):e012287. Available from: https://doi.org/ 10.1136/bmjopen-2016- 012287 https://doi.org/ 10.1136/bmjopen-2016- 0...	2016	5	Explore the association between the components of the hospital discharge process, including subsequent continuity of care and patient outcomes in the post-discharge period.	Regardless of the discharge process, this review found no association between hospital discharge and patient health outcome, but addressed the importance of hospital discharge planning.
Kable A, et al.2929. Kable A, Chenoweth L, Pond D, Hullick C. Health professional perspectives on systems failures in transitional care for patients with dementia and their carers: A qualitative descriptive study. BMC Health Serv Res [Internet]. 2015 [cited 2020 Jul 15];15:567. Available from: https://doi.org/10.1186/s12913-015-1227-z https://doi.org/10.1186/s12913-015-1227-...	2015	6	Report to community health professionals, residents and clinicians about the discharge process and transition arrangements for people with dementia and their caregivers.	Described discharge planning and transitional care as a complex process with multiple employees and components. Two themes emerged: barriers to effective planning of discharge of people with disabilities and their caregivers and failures in the process of care transition and the associated results for discharge of people with dementia.
Rattray NA, et al.3030. Rattray NA, Sico JJ, Cox LAM, Russ AL, Matthias MS, Frankel RM. Crossing the communication chasm: Challenges and opportunities in transitions of care from the hospital to the primary care clinic. Jt Comm J Qual Patient Saf [Internet]. 2017 [cited 2020 Jul 15];43(3):127-37. Available from: https://doi.org/10.1016/j.jcjq.2016.11.007 https://doi.org/10.1016/j.jcjq.2016.11.0...	2017	6	Investigate barriers and facilitators of effective communication between stroke patients/transient ischemic attack and primary care providers.	Ambiguity about who is being transferred and time pressures in the acute scenario can lead inpatient professionals to give lower priority to discharge communication, leaving outpatient health professionals with poor quality information. Although electronic models have standardized the main components of discharge documentation, opportunities for improvement remain.
Lindquist LA, et al.3131. Lindquist LA, Miller RK, Saltsman WS, Carnahan J, Rowe TA, Arbaje AI, et al. SGIM-AMDA-AGS consensus best practice recommendations for transitioning patients’ healthcare from skilled nursing facilities to the community. J Gen Intern Med [Internet]. 2017 [cited 2020 Jul 18];32(2):199-203. Available from: https://doi.org/10.1007/s11606-016-3850-8 https://doi.org/10.1007/s11606-016-3850-...	2017	7	Identify best practice recommendations for optimal home transitions.	Presents a set of actionable items that can be implemented in a daily workflow in post-discharge care transitions. The goal of these good practices recommended by consensus is to provide a safe and high-quality transition for patients moving between hospital care and primary care.
Stella SA, et al.3232. Stella SA, Keniston A, Frank MG, Heppe D, Mastalerz K, Lones J, et al. Postdischarge telephone calls by hospitalists as a transitional care strategy. Am J Manag Care [Internet]. 2016 [cited 2020 Jul 1];22(10):e338-42. Available from: https://www.ajmc.com/view/postdischarge-telephone-calls-by-hospitalists-as-a-transitional-care-strategy https://www.ajmc.com/view/postdischarge-...	2016	4	Determine whether the treatment of hospital physicians can identify and resolve early discharge problems through a structured telephone call.	The treatment of physicians identified problems in more than half of the patients contacted by telephone shortly after discharge, the highest proportion of which were new or aggravating symptoms. They were able to resolve most of the problems identified through a brief telephone contact without using additional resources.
Record JD, et al.3333. Record JD, Niranjan-Azadi A, Christmas C, Hanyok LA, Rand CS, Hellmann DB, Ziegelstein RC . Telephone calls to patients after discharge from the hospital: an important part of transitions of care. Med Educ Online [Internet]. 2015 [cited 2020 Jul 1];20:1. Available from: https://doi.org/10.3402/meo.v20.26701 https://doi.org/10.3402/meo.v20.26701...	2015	4	Explore associations between patient-centered care and patients' perspectives on the quality of transition care - Care Transitions Measure (CTM-3).	Post-discharge telephone call, an element of patient-centered care, was associated with higher CTM-3 scores, which, in turn, demonstrated to decrease the risk of patients performing emergency visits within 30 days after discharge.
Hewner S, et al.3434. Hewner S, Sullivan SS, Yu G. Reducing emergency room visits and in-hospitalizations by implementing best practice for transitional care using innovative technology and big data. Worldviews Evid Based Nurs [Internet]. 2018 [cited 2020 May 24];15(3):170-7. Available from: https://doi.org/10.1111/wvn.12286 . https://doi.org/10.1111/wvn.12286...	2018	4	Demonstrate the feasibility of implementing the Transition Coordinating Intervention in a primary care environment to reduce hospitalizations by delivering evidence-based clinical decision support to the right person, in the right place, at the right time using health information exchanges.	Positive results with the use of technology. Technology has the potential to support quality improvement processes throughout care by providing relevant and actionable evidence-based information to the right person, location, time, and path when integrated into existing workflows.
The S.3535. Yang S. Impact of pharmacist-led medication management in care transitions. BMC Health Serv Res [Internet]. 2017 [cited 2020 May 24];17(1):722. Available from: https://doi.org/10.1186/s12913-017-2684-3 . https://doi.org/10.1186/s12913-017-2684-...	2017	4	Determine whether a pharmacist's telephone follow-up intervention focused on supporting patient medication management is associated with a reduction in readmission rates within 30 days; describe the number and types of interventions of the pharmacist in the care transitions.	Post-discharge pharmaceutical guidance by telephone did not reduce readmission, but was important for patient safety.
Phatak A, et al.3636. Phatak A, Prusi R, Ward B, Hansen LO, Williams MV, Vetter E, et al. Impact of pharmacist involvement in the transitional care of high-risk patients through medication reconciliation, medication education, and postdischarge call-backs (IPITCH Study). J Hosp Med [Internet]. 2016 [cited 2020 Jul 18];11(1):39-44. Available from: https://doi.org/10.1002/jhm.2493 . https://doi.org/10.1002/jhm.2493...	2016	2	Evaluate the impact of pharmacist involvement in care transitions, measured by decreased medication errors and adverse drug events, 30-day readmissions, and visits to the emergency department.	The performance of pharmacists had a positive impact on the reduction or prevention of adverse events with medications, hospital admissions and emergency visits.
Ballard J, et al.3737. Ballard J, Rankin W, Roper KL, Weatherford S, Cardarelli R. Effect of ambulatory transitional care management on 30-day readmission rates. Am J Med Qual [Internet]. 2018 [cited 2020 June 30];33(6):583-9. Available from: https://doi.org/10.1177/1062860618775528 https://doi.org/10.1177/1062860618775528...	2018	4	Report the results of the largest and longest known study to date evaluating the possible reduction in the 30-day readmission rate using Medicare requirements for Transition Care Management (CTM) services in a single practice site and determine how the CTM contributes to reductions in 30-day readmission rates.	This study provides evidence that primary care-based CTM can reduce readmissions by 30 days.
Wong S, et al.3838. Wong S, Montoya L, Quinlan B. Transitional care post TAVI: A pilot initiative focused on bridging gaps and improving outcomes. Geriatr Nurs (Minneap) [Internet]. 2018 [cited 2020 Jul 15];39(5):548-53. Available from: https://doi.org/10.1016/j.gerinurse.2018.03.003 https://doi.org/10.1016/j.gerinurse.2018...	2018	6	Incorporate traditional care strategies into a protocol developed to monitor patients with transcatheter aortic valve (TAVI) implantation after discharge.	The involvement of the post-TAVI advanced practice nurse was essential to ensure the careful assessment and management of the main risks after discharge. Patients followed by the nurse had lower rates of readmission than found in the literature.
Wong FK a. Y, et al.3939. Wong FKY, So C, Chau J, Law AKP, Tam SKF, McGhee S. Economic evaluation of the differential benefits of home visits with telephone calls and telephone calls only in transitional discharge support. Age Ageing [Internet]. 2015 [cited 2020 Jul 15];44(1):143-7. Available from: https://doi.org/10.1093/ageing/afu166 . https://doi.org/10.1093/ageing/afu166...	2015	2	Examine the differential economic benefits of home visits with phone calls and only phone calls in the transient discharge support.	The grouped intervention involving home visits and calls was more effective than just calls in reducing readmissions. However, when the cost factor is included, the complex intervention of the combined use of visits and home connections may not necessarily have the advantage of calls only.
Galbraith AA, et al.4040. Galbraith AA, Meyers DJ, Ross-Degnan D, Burns ME, Vialle-Valentin CE, Larochelle MR, et al. Long-term impact of a postdischarge community health worker intervention on health care costs in a safety-net system. Health Serv Res [Internet]. 2017 [cited 2020 May 24];52(6):2061-78. Available from: https://doi.org/10.1111/1475-6773.12790 . https://doi.org/10.1111/1475-6773.12790...	2017	2	Assess the impact of an intervention for high-risk patients on health system costs 180 days after discharge.	A post-discharge intervention with community health agents providing transitional care for high-risk patients in a safety environment reduced costs by 180 days for older patients and did not significantly increase overall costs for younger patients.
Finlayson K, et al.4141. 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 [Internet]. 2018 [cited 2020 June 20];18:956. Available from: https://doi.org/10.1186/s12913-018-3771-9 https://doi.org/10.1186/s12913-018-3771-...	2018	2	Evaluate the comparative efficacy of transition care interventions in unplanned hospital readmissions within 28 days, 12 weeks and 24 weeks after hospital discharge.	Multifaceted transitional care interventions in hospital and community settings are beneficial, with lower hospital readmission rates, although only in the first 12 weeks.
Pacho C, et al.4242. Pacho C, Domingo M, Núñez R, Lupón J, Moliner P, de Antonio M, et al. Una consulta específica al alta (STOP-HF-Clinic) reduce los reingresos a 30 días de los pacientes ancianos y frágiles con insuficiencia cardiaca. Rev Española Cardiol [Internet]. 2017 [cited 2020 June 20];70(8):631-8. Available from: https://doi.org/10.1016/j.recesp.2016.12.026 https://doi.org/10.1016/j.recesp.2016.12...	2017	4	Evaluate a structured multidisciplinary outpatient consultation for elderly and frail patients with HF after discharge; the impact of the consultation intervention on the readmission data.	This intervention contributed to a 50% reduction in the readmission rate for any cause within 30 days of discharge of HF patients. The results with the multidisciplinary outpatient consultation structured in the elderly, fragile population and with comorbidities were better than those of other strategies.
Jackson C, et al.4343. Jackson C, Shahsahebi M, Wedlake T, Dubard CA. Timeliness of outpatient follow-up: an evidence-based approach for planning after hospital discharge. Ann Fam Med [Internet]. 2015 [cited 2020 Jul 1];13(2):115-22. Available from: https://doi.org/10.1370/afm.1753 . https://doi.org/10.1370/afm.1753...	2015	4	Identify the ideal time of hospital follow-up for patients with conditions of varying complexity.	The benefit of early outpatient follow-up after hospital discharge varies according to the clinical complexity of the patient. Although 7-day follow-up has been associated with substantially lower readmission rates among patients with greater clinical complexity and higher risk of readmission, most patients do not seem to benefit from very early follow-up.
Federman AD, et al.4444. Federman AD, Soones T, DeCherrie L V., Leff B, Siu AL. Association of a bundled hospital-at-home and 30-day postacute transitional care program with clinical outcomes and patient experiences. JAMA [Internet]. 2018 [cited 2020 Jul 9];178(8):1033-41. Available from: https://doi.org/10.1001/ jamainternmed.2018.2562 https://doi.org/10.1001/ jamainternmed.2...	2018	4	Report the results of the new model of hospital care at home.	Patients who had care at home in the 30 days after discharge from the service had the lowest hospitalization time; the lowest readmission rates, emergency visits, institutionalization and the best service ratings.
Low LL, et al.4545. Low LL, Vasanwala FF, Ng LB, Chen C, Lee KH, Tan SY. Effectiveness of a transitional home care program in reducing acute hospital utilization: A quasi-experimental study. BMC Health Serv Res [Internet]. 2015 [cited 2020 June 30];15:100. Available from: https://doi.org/10.1186/s12913-015-0750-2 https://doi.org/10.1186/s12913-015-0750-...	2015	4	To assess whether the transition home care program operated by the Singapore General Hospital was effective in reducing acute hospital use.	Patients who participated in the home care program during the transition had lower rates of hospital use, with reduced hospitalizations and emergency care. There is growing evidence that supports the effectiveness of multidisciplinary transitional care programs in reducing the use of hospital resources.
Ritchie K, et al.4646. Ritchie K, Duff-Woskosky A, Kipping S. Mending the cracks: a case study in using technology to assist with transitional care for persons with dementia. Nurs Leadersh (Tor Ont) [Internet]. 2017 [cited 2020 Jul 18];30(3):54-62. Available from: https://doi.org/10.12927/cjnl.2018.25385 https://doi.org/10.12927/cjnl.2018.25385...	2017	6	Customize the electronic medical records to create a specific interprofessional care plan for dementia patients; use electronic medical records to facilitate a timely transition of information to community health care providers.	Use of the technology, which is an important means to facilitate and inform care, will help the transition of knowledge between the hospital and the community of adults with dementia.
Wang QQ, et al.4747. Wang QQ, Zhao J, Huo XR, Wu L, Yang LF, Li JY, et al. Effects of a home care mobile app on the outcomes of discharged patients with a stoma: A randomised controlled trial. J Clin Nurs [Internet]. 2018 [cited 2020 June 20];27(19-20):3592-602. Available from: https://doi.org/10.1111/jocn.14515 https://doi.org/10.1111/jocn.14515...	2018	2	Explore the effects of a mobile home care app with stoma patients who were discharged from the hospital.	Home follow-up through a mobile app can improve the level of psychosocial adjustment, the scale of self-efficacy, and other outcomes related to stoma patients. The application is an effective intervention to support psychosocial adjustment and self-efficacy of stomized patients after discharge. Ensures continuity of care and provides nursing guidance to patients in a timely manner.
Barber RD, et al.4848. Barber RD, Kogan AC, Riffenburgh A, Enguidanos S. A role for social workers in improving care setting transitions: A case study. Soc Work Heal Care [Internet]. 2015 [cited 2020 June 20];54(3):177-92. Available from: https://doi.org/10.1080/00981389.2015.1005273 . https://doi.org/10.1080/00981389.2015.10...	2015	6	Provide information on how a social worker can improve the transition experience and health outcomes for the elderly.	The inclusion of social workers in transition care interventions can provide better connections with health services and based on the community, in addition to greater psychosocial support that leads to positive results in sustainable health.
Toles M, et al.4949. Toles M, Colón-Emeric C, Asafu-Adjei J, Moreton E, Hanson LC. Transitional care of older adults in skilled nursing facilities: A systematic review. Geriatr Nurs (Minneap) [Internet]. 2016 [cited 2020 June 20];37(4):296-301. Available from: https://doi.org/10.1016/j.gerinurse.2016.04.012 https://doi.org/10.1016/j.gerinurse.2016...	2016	5	Identify whether transition care interventions, compared to usual care, improved clinical outcomes such as mortality, readmission rates, quality of life or functional status and describe the characteristics of the interventions, resources needed for implementation and methodological challenges.	The results suggest promising but limited evidence that transitional care improves patient clinical outcomes.
Kansagara D, et al.5050. Kansagara D, Chiovaro JC, Kagen D, Jencks S, Rhyne K, O’Neil M, et al. So many options, where do we start? An overview of the care transitions literature. J Hosp Med [Internet]. 2016 [cited 2020 June 30];11(3):221-30. Available from: https://doi.org/10.1002/jhm.2502 . https://doi.org/10.1002/jhm.2502...	2016	1	Summarize the effects on health and the use of transition care interventions and identify common themes about types of interventions, patient populations or contexts that modify these effects.	There was consistent evidence that improved discharge planning and hospital interventions at home reduced readmissions.
The Berre M, et al.5151. Le Berre M, Maimon G, Sourial N, Guériton M, Vedel I. Impact of transitional care services for chronically ill older patients: A systematic evidence review. J Am Geriatr Soc [Internet]. 2017 [cited 2020 Jul 9];65(7):1597-608. Available from: https://doi.org/10.1111/jgs.14828. https://doi.org/10.1111/jgs.14828....	2017	1	Determine the efficacy of interventions directed to the transitions from the hospital to primary care to elderly patients with chronic diseases.	Transition care for elderly patients with chronic diseases who were discharged from the hospital to home obtained the best results in reducing mortality and readmissions.
Hwang U, et al.5252. Hwang U, Dresden SM, Rosenberg MS, Garrido MM, Loo G, Sze J, et al. Geriatric emergency department innovations: transitional care nurses and hospital use. J Am Geriatr Soc [Internet]. 2018 [cited 2020 Jul 9];66(3):459-66. Available from: https://doi.org/10.1111/jgs.15235 https://doi.org/10.1111/jgs.15235...	2018	4	Examine the effect of transition care for a nurse in the emergency department.	Patients who received care from transition nurses in the emergency room, had lower hospitalization rates and emergency room visits.
Robertson FC, et al.5353. Robertson FC, Logsdon JL, Dasenbrock HH, Yan SC, Raftery SM, Smith TR, et al. Transitional care services: A quality and safety process improvement program in neurosurgery. J Neurosurg [Internet]. 2018 [cited 2020 Jul 18];128(5):1570-7. Available from: https://doi.org/10.3171/2017.2.JNS161770 https://doi.org/10.3171/2017.2.JNS161770...	2018	4	Establish a transition care program with the objective of reducing the length of stay, improving discharge efficiency and reducing the readmission of neurosurgical patients, optimizing patient education and post-discharge surveillance.	The program was able to reduce the time of hospitalization, readmissions and improved the patient experience and the quality of care.
Bindman AB, Cox DF.5454. Bindman AB, Cox DF. Changes in health care costs and mortality associated with transitional care management services after a discharge among medicare beneficiaries. JAMA [Internet]. 2018 [cited 2020 Jul 18];178(9):1283. Available from: https://doi.org/10.1001/jamainternmed.2018.2572 https://doi.org/10.1001/jamainternmed.20...	2018	4	Investigating whether receiving transitional care was associated with lower subsequent health costs and beneficiaries' mortality in the month following the provision of the service.	Medicare beneficiaries who received transitional care had lower total costs and mortality compared to those who did not receive these services.
Heim N, et al.5555. Heim N, Rolden H, Fenema EM, Weverling-Rijnsburger AWE, Tuijl JP, Jue P, et al. The development, implementation and evaluation of a transitional care programme to improve outcomes of frail older patients after hospitalization. Age Ageing [Internet]. 2016 [cited 2020 Jul 18];45(5):642-51. Available from: https://doi.org/10.1093/ageing/afw098 https://doi.org/10.1093/ageing/afw098...	2016	6	Inform about the development, implementation and evaluation of a regional transitional care program, with the objective of improving the recovery rate of hospitalized and frail elderly patients.	By involving stakeholders in the design and development of the transitional care program, the commitment of health professionals has been guaranteed. Viable innovations in integrated transitional care for frail elderly patients after hospitalization were implemented sustainably within health organizations.
Acosta AM, et al.5656. Acosta AM, Câmara CE, Weber LAF, Fontenele RM. Atividades do enfermeiro na transição do cuidado: realidades e desafios. Rev Enferm UFPE online [Internet]. 2018 [cited 2020 May 20];12(12):3190-6. Available from: https://doi.org/10.5205/1981-8963-v12i12a231432p3190-3197-2018 https://doi.org/10.5205/1981-8963-v12i12...	2018	6	To analyze the activities performed by nurses in the transition from care to patients discharged from the hospital.	It was possible to evaluate the most frequent activities of nurses in the care transition, among them, the main one was education and health. The main difficulty was contact with primary care and follow-up of the post-discharge outcome.
Weber LAF, et al.5757. Weber LAF, Lima MAD da S, Acosta AM, Marques GQ. Transição do cuidado do hospital para o domicílio: revisão integrativa. Cogitare Enferm [Internet]. 2017 [cited 2020 May 10];22(3):e47615. Available from: https://doi.org/10.5380/ce.v22i3.4761 https://doi.org/10.5380/ce.v22i3.4761...	2017	6	To identify nurses' activities in the transition from hospital to home care based on evidence in the literature.	The activities of nurses to develop care coordination in the transition from hospital to home include drug reconciliation, patient and/or caregiver guidance, home follow-up of the patient after hospital discharge, effective communication between the hospital and other health services, and support in the community.
Whitehouse CR, et al.5858. Whitehouse CR, Sharts-Hopko NC, Smeltzer SC et al. Supporting transitions in care for older adults with type 2 diabetes mellitus and obesity. Res Gerontol Nurs [Internet]. 2018 [cited 2020 June 20];11(2):71-81. Available from: https://doi.org/10.3928/19404921-20180223-02 . https://doi.org/10.3928/19404921-2018022...	2018	4	To compare the results of elderly with type 2 diabetes mellitus and obesity after participation in a transition care intervention that included self-management education of diabetes and home care.	Rates of rehospitalization and glycemic control were analyzed, but did not have a large decrease, possibly due to the other comorbidities of each patient.
Aued GK, et al.5959. Aued GK, Bernardino E, Lapierre J, Dallaire C. Atividades das enfermeiras de ligação na alta hospitalar: uma estratégia para a continuidade do cuidado. Rev Latino-Am Enfermagem [Internet]. 2019 [cited 2020 Jul 12];27:e3162. Available from: https://doi.org/10.1590/1518-8345.3069.3162 https://doi.org/10.1590/1518-8345.3069.3...	2019	6	Describe the activities developed by liaison nurses for continuity of care after hospital discharge.	Highlights the importance of hospitals appointing a professional to coordinate the hospital discharge process, playing the role of articulator between professionals, between services at different levels of care and advocating for the benefit of the patient. Without coordination actions, it is difficult to promote continuity of care. Suggests the implementation of the position of nurse liaison or a liaison service within the hospital.
Costa MFBNA et al.6060. Costa MFBNA da, Andrade SR De, Soares CF, Pérez EIB, Bernardino E. A continuidade do cuidado de enfermagem hospitalar para a Atenção Primaria à Saúde na Espanha. Rev Esc Enferm USP [Internet]. 2019 [cited 2020 Jul 12];53:1-8. Available from: https://doi.org/10.1590/s1980-220x2018017803477 https://doi.org/10.1590/s1980-220x201801...	2019	6	To know the profile and activities performed by the Hospital Nurse of Enlace for the continuity of care in Primary Health Care in Spain.	It is necessary to have capacity as an educator, work as a team and motivation. Activities include availability of resources and experience in the management of care for complex patients and their families.
Hestevik CH, et al. 6161. Hestevik CH, Molin M, Debesay J, Bergland A, Bye A. Older persons’ experiences of adapting to daily life at home after hospital discharge: A qualitative metasummary. BMC Health Serv Res [Internet]. 2019 [cited 2020 May 20];19:224. Available from: https://doi.org/10.1186/s12913-019-4035-z https://doi.org/10.1186/s12913-019-4035-...	2019	5	Integrate current international findings in order to improve the understanding of the experiences of the elderly of adaptation to daily life at home after hospital discharge.	The results emphasize the importance of evaluation and planning, information and education, preparation of the home environment, involvement of the elderly and caregivers and support for self-management in the processes of discharge and follow-up at home.
Backman C, et al. 6262. Backman C, Stacey D, Crick M, Cho-Young D, Marck PB. Use of participatory visual narrative methods to explore older adults’ experiences of managing multiple chronic conditions during care transitions. BMC Health Serv Res [Internet]. 2018 [cited 2020 Jul 12];18:482. Available from: https://doi.org/10.1186/s12913-018-3292-6 https://doi.org/10.1186/s12913-018-3292-...	2018	6	Involve the elderly with various chronic conditions and their families in the detailed exploration of their experiences during transitions in health environments and identify potential areas for future interventions.	It is important to strengthen support for care centered on the person and family, involving the elderly and families in their care transitions, providing better support and resources.

Universidade Federal de Santa Catarina, Programa de Pós Graduação em Enfermagem Campus Universitário Trindade, 88040-970 Florianópolis - Santa Catarina - Brasil, Tel.: (55 48) 3721-4915 / (55 48) 3721-9043 - Florianópolis - SC - Brazil
E-mail: textoecontexto@contato.ufsc.br

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Jociele Gheno pita.gheno@hotmail.com