Challenges in the transition of hospital care for individuals with chronic diseases: a mixed-methods study.

OBJECTIVE

To analyze the transition of care from hospital to home from the perspective of people with chronic diseases and healthcare professionals in a private hospital.

METHOD: A sequential explanatory mixed-methods study conducted in Southern Brazil. The quantitative phase included 166 individuals with chronic diseases assessed after hospital discharge using the Care Transitions Measure. The qualitative phase comprised two focus groups with healthcare professionals (n=9; n=7).

RESULTS

The overall evaluation of care transition found them to be unsatisfactory (62.62±9.03). The highest score was observed in Health Management (73.24±10.24) and the lowest in Care Plan (56.12±17.56). Men presented higher scores in Health Management (p=0.008), Care Plan (p=0.005), and overall evaluation (p<0.001). Being in a stable relationship was associated with better Care Plan (p=0.002), and higher educational level with better Medication Understanding (p=0.016) and overall evaluation (p=0.011). The qualitative stage revealed shortcomings in discharge planning, interprofessional communication, and patient and family participation.

CONCLUSIONS

Care transition was unsatisfactory, indicating the need to improve discharge planning, strengthen interprofessional communication, and enhance patient engagement.