Transitional care process in the dehospitalization of elderly people: a qualitative approach

Abstract

INTRODUCTION: Transition care is an ethical, economical strategy focused on comprehensive healthcare, especially during transfers between care settings. OBJECTIVE: This study aimed to identify the understanding of a multidisciplinary team regarding transition care in the process of discharging elderly patients from a geriatric hospital in Salvador, Bahia. METHOD: This is a qualitative, field-based, exploratory, and descriptive study. Fourteen health professionals were interviewed using a structured questionnaire and semi-structured interview. The analysis was conducted based on Bardin's content analysis technique. RESULTS AND DISCUSSION: Participants demonstrated partial understanding of transition care, with an emphasis on continuity of care at the time of hospital discharge. Structural, communication, and training difficulties were pointed out, in addition to the absence of integrated care plans. The role of psychology was highlighted as a differentiating factor, especially in skilled listening, supporting the psychosocial adaptation of the elderly person, and mediating with the team and family members. Lack of knowledge about the Care Transitions Measure scale as an assessment tool was identified. Most participants expressed interest in receiving training on the topic. CONCLUSION: There is a need to improve care transition practices in the dehospitalization of older adults, with a focus on continuing education for teams and greater coordination with the healthcare network. Psychology stands out as a mediator in the development of contextualized care plans, contributing to comprehensive care for older adults.