ABSTRACT
Objective:
to understand discharge plan and the facilities and difficulties for continuity of care in Primary Health Care.
Method:
a qualitative and exploratory study carried out in Madrid, Barcelona, Murcia, Seville and Granada, with 29 hospital liaison nurses working in university hospitals, between 2016 and 2018. For data collection, an online questionnaire was used with open and closed questions about the profile of nurses; work context; hospital discharge plan; communication between hospital nurses and primary care. All were analyzed based on Thematic Analysis.
Results:
hospital liaison nurses from Spain draw up a discharge plan at least 48 hours in advance. They offer a Continuity of Care Report, guide patients, families and caregivers to the necessary care after hospital discharge, coordinate consultations and referrals and carry out home visits. Communication with primary care occurs through the computerized system and telephone. Monitoring takes place using indicators and statistical reports. In cases of readmission, nurses are requested and contacted by nurses in primary care. Communication with primary care is among the facilities. Lack of liaison nurses is among the difficulties.
Conclusion:
hospital liaison nurses from Spain carry out a discharge plan and communicate with primary care. When patients are hospitalized, they are called when there is a need for continuity of care for primary care.
DESCRIPTORS
Transitional care; Patient discharge; Continuity of patient care; nurse; Primary health care