Transition of care for patients with Covid-19 from the hospital to other points in the care network: contributions from clinic management

Abstract

Introduction: The transition of care from hospital care to other points in the health care network constitutes a challenge to contemporary health management, as, depending on how it occurs, it can influence the patient’s experience, as well as quality, safety and effectiveness of care. From the point of view of clinic management, a model that is guided by scientific evidence and consists of micromanagement technologies that aim for quality health care, this transition must be centered on the persons using the services and their health demands, aiming for better results and comprehensive care. However, in pandemic contexts, the transition of care can be compromised, and it is important and necessary to recognize this, in order to propose clinical management mechanisms that enhance an effective transition. Objective: to evaluate the transition of care for post-Covid-19 patients, from the hospital to other points in the health care network, in light of clinic management. Methods: This is a cross-sectional study with 29 patients, approached after discharge from a federal public hospital in the Brazilian center-west. An instrument was used for sociodemographic characterization, another containing information on hospitalization and clinical status, as well as to assess the quality and experience of patients in the care transition, the Care Transitions Measure (CTM-15) instrument was completed. Results: The transition of patient care, from hospital services to other points in the care network, was satisfactory in the investigated context, with an average score of 74.7. Among the factors evaluated, the one related to preparation for discharge had the highest score while the one related to the care plan had the lowest. There was a significant association between the CTM-15 factors and age, income and days spent in the ICU. Conclusion: From the perspective of clinical management, effective transition is achieved through the formulation and development of strategies and processes that allow satisfactory responses to the different demands related to transitional care, which is equivalent to implementing structural and procedural solutions for coordination, continuity of care and assistance integration, centered on the individual and their family, throughout the care continuum. The study points to the need and importance of involvement between the different actors involved in the production of care, in the construction of care plans that consider knowledge and potential to ensure the
continuity and effectiveness of care.