{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,3,30]],"date-time":"2026-03-30T14:00:33Z","timestamp":1774879233178,"version":"3.50.1"},"reference-count":40,"publisher":"FapUNIFESP (SciELO)","license":[{"start":{"date-parts":[[2026,1,1]],"date-time":"2026-01-01T00:00:00Z","timestamp":1767225600000},"content-version":"vor","delay-in-days":0,"URL":"http:\/\/creativecommons.org\/licenses\/by\/4.0\/"},{"start":{"date-parts":[[2026,1,1]],"date-time":"2026-01-01T00:00:00Z","timestamp":1767225600000},"content-version":"am","delay-in-days":0,"URL":"http:\/\/creativecommons.org\/licenses\/by\/4.0\/"},{"start":{"date-parts":[[2026,1,1]],"date-time":"2026-01-01T00:00:00Z","timestamp":1767225600000},"content-version":"tdm","delay-in-days":0,"URL":"http:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["Rev. Bras. Enferm."],"abstract":"<jats:p>ABSTRACT  Objectives: to propose an outpatient discharge management model from specialized care to primary care to promote continuity of care for chronic conditions.  Methods: action research with a qualitative approach. Twenty-eight professionals, including physicians, nurses, and public administrators, participated. Data collection was carried out through participant observation, documentary research, semi-structured interviews, and workshops. The data were subjected to Creswell\u2019s content analysis.  Results: eight categories and 22 subcategories supported the creation of the outpatient discharge management model, emphasizing communication among levels of the healthcare network, designating the nurse as the process coordinator, and encouraging collaborative practices.  Final Considerations: the study proposed an outpatient discharge management model focused on continuity of care, in addition to reinforcing the role of nurses, highlighting attention to communication, technological support and collaborative practices, reaffirming the importance of Primary Health Care as a care organizer.<\/jats:p>","DOI":"10.1590\/0034-7167-2025-0221","type":"journal-article","created":{"date-parts":[[2026,2,13]],"date-time":"2026-02-13T11:10:40Z","timestamp":1770981040000},"source":"Crossref","is-referenced-by-count":0,"title":["Outpatient discharge management model: a strategy to promote continuity of care"],"prefix":"10.1590","volume":"79","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-4790-0562","authenticated-orcid":false,"given":"Daniele Cristina dos Reis","family":"Bobrowec","sequence":"first","affiliation":[{"name":"Universidade Federal do Paran\u00e1,  Brazil"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-1321-8562","authenticated-orcid":false,"given":"Elizabeth","family":"Bernardino","sequence":"additional","affiliation":[{"name":"Universidade Federal do Paran\u00e1,  Brazil"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-5914-1105","authenticated-orcid":false,"given":"Gisele Knop","family":"Aued","sequence":"additional","affiliation":[{"name":"Universidade Federal do Rio Grande do Sul,  Brazil"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-4249-4809","authenticated-orcid":false,"given":"Jaqueline Dias do Nascimento","family":"Selleti","sequence":"additional","affiliation":[{"name":"Universidade Federal do Paran\u00e1,  Brazil"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-1527-9940","authenticated-orcid":false,"given":"Maria Manuela Ferreira Pereira da Silva","family":"Martins","sequence":"additional","affiliation":[{"name":"Universidade do Porto,  Portugal"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-8111-4621","authenticated-orcid":false,"given":"Camila","family":"Rorato","sequence":"additional","affiliation":[{"name":"Universidade Federal do Paran\u00e1,  Brazil"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-9258-7675","authenticated-orcid":false,"given":"Keyla Cristina da Rocha","family":"Fracarolli","sequence":"additional","affiliation":[{"name":"Universidade Federal do Paran\u00e1,  Brazil"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-3216-1645","authenticated-orcid":false,"given":"L\u00edvia Cozer","family":"Montenegro","sequence":"additional","affiliation":[{"name":"Universidade Federal do Paran\u00e1,  Brazil"}]}],"member":"530","published-online":{"date-parts":[[2026]]},"reference":[{"key":"ref1","series-title":"Continuity and coordination of care: a practice brief to support implementation of the WHO framework on integrated people-centred health services","year":"2018"},{"issue":"9","key":"ref2","doi-asserted-by":"crossref","first-page":"e00047122","DOI":"10.1590\/0102-311xpt047122","article-title":"Continuidade da gest\u00e3o cl\u00ednica entre n\u00edveis assistenciais: experi\u00eancias dos usu\u00e1rios de uma rede municipal de sa\u00fade","volume":"38","author":"Guerra S","year":"2022","journal-title":"Cad Sa\u00fade P\u00fablica"},{"issue":"spe1","key":"ref3","doi-asserted-by":"crossref","first-page":"244","DOI":"10.1590\/0103-11042018s116","article-title":"Coordena\u00e7\u00e3o do cuidado e Aten\u00e7\u00e3o Prim\u00e1ria \u00e0 Sa\u00fade no Sistema \u00danico de Sa\u00fade","volume":"42","author":"Almeida PF","year":"2018","journal-title":"Sa\u00fade Debate"},{"key":"ref4","doi-asserted-by":"crossref","first-page":"e20220100","DOI":"10.1590\/1980-220x-reeusp-2022-0100en","article-title":"Continuity and coordination of care: conceptual interface and nurses\u2019 contributions","volume":"56","author":"Santos MT","year":"2022","journal-title":"Rev Esc Enferm USP"},{"key":"ref5","series-title":"Implanta\u00e7\u00e3o das redes de aten\u00e7\u00e3o \u00e0 sa\u00fade e outras estrat\u00e9gias da SAS","volume-title":"Secretaria de Aten\u00e7\u00e3o \u00e0 Sa\u00fade","year":"2014"},{"issue":"4","key":"ref6","doi-asserted-by":"crossref","first-page":"323","DOI":"10.1590\/S0080-62341999000400001","article-title":"Organiza\u00e7\u00e3o do sistema de refer\u00eancia e contra-refer\u00eancia no contexto do Sistema \u00danico de Sa\u00fade: a percep\u00e7\u00e3o de enfermeiro","volume":"33","author":"Juliani CMCM","year":"1999","journal-title":"Rev Esc Enferm USP"},{"issue":"7","key":"ref7","article-title":"A\u00e7\u00f5es de refer\u00eancia e contrarrefer\u00eancia para a transi\u00e7\u00e3o do cuidado na Aten\u00e7\u00e3o Prim\u00e1ria \u00e0 Sa\u00fade","volume":"23","author":"Caixeta DES","year":"2023","journal-title":"Rev Eletr Acervo Sa\u00fade"},{"issue":"1","key":"ref8","doi-asserted-by":"crossref","first-page":"e310105","DOI":"10.1590\/s0103-73312021310105","article-title":"Referral and counter-referral for the integrality of care in the Health Care Network","volume":"31","author":"Oliveira CCRB","year":"2021","journal-title":"Physis"},{"issue":"3","key":"ref9","doi-asserted-by":"crossref","first-page":"941","DOI":"10.1590\/1413-81232017223.18842016","article-title":"Aten\u00e7\u00e3o especializada ambulatorial no Sistema \u00danico de Sa\u00fade: para superar um vazio","volume":"22","author":"Tesser CD","year":"2017","journal-title":"Ci\u00eanc Sa\u00fade Coletiva"},{"key":"ref10","doi-asserted-by":"crossref","first-page":"3579","DOI":"10.1590\/S1413-81232010000900033","article-title":"Avalia\u00e7\u00e3o da refer\u00eancia e contrarrefer\u00eancia no Programa Sa\u00fade da Fam\u00edlia na Regi\u00e3o Metropolitana do Rio de Janeiro (RJ, Brasil)","volume":"15","author":"Serra CG","year":"2010","journal-title":"Ci\u00eanc Sa\u00fade Coletiva"},{"issue":"1","key":"ref11","doi-asserted-by":"crossref","first-page":"01","DOI":"10.5380\/ce.v21i1.43350","article-title":"Desafios da refer\u00eancia e contrarrefer\u00eancia na aten\u00e7\u00e3o em sa\u00fade na perspectiva dos trabalhadores","volume":"21","author":"Brondani JE","year":"2016","journal-title":"Cogitare Enferm"},{"issue":"38","key":"ref12","first-page":"173","article-title":"Transi\u00e7\u00e3o e continuidade do cuidado na percep\u00e7\u00e3o dos enfermeiros da aten\u00e7\u00e3o prim\u00e1ria \u00e0 sa\u00fade","volume":"12","author":"Gallo VCL","year":"2022","journal-title":"Rev Recien"},{"key":"ref13","doi-asserted-by":"crossref","first-page":"e20240091","DOI":"10.1590\/1980-265x-tce-2024-0091en","article-title":"Counter-referral difficulties in an emergency care unit: impact of covid-19","volume":"33","author":"Freitas BM","year":"2024","journal-title":"Texto Contexto Enferm"},{"key":"ref14","first-page":"e4","article-title":"Recommendations to strengthen primary health care in Brazil","volume":"44","author":"Tasca R","year":"2020","journal-title":"Rev Panam Salud Publica"},{"issue":"3","key":"ref15","doi-asserted-by":"crossref","first-page":"189","DOI":"10.15441\/ceem.18.022","article-title":"Emergency department and hospital crowding: causes, consequences, and cures","volume":"6","author":"McKenna P","year":"2019","journal-title":"Clin Exp Emerg Med"},{"issue":"6","key":"ref16","doi-asserted-by":"crossref","first-page":"963","DOI":"10.1093\/jamia\/ocaa039","article-title":"Balancing health privacy, health information exchange, and research in the context of the COVID-19 pandemic","volume":"27","author":"Lenert L","year":"2020","journal-title":"J Am Med Inform Assoc"},{"key":"ref17","series-title":"Programa Melhor em Casa","year":"2025"},{"issue":"121","key":"ref18","doi-asserted-by":"crossref","first-page":"592","DOI":"10.1590\/0103-1104201912123","article-title":"A aten\u00e7\u00e3o domiciliar no \u00e2mbito do Sistema \u00danico de Sa\u00fade: desafios e potencialidades","volume":"43","author":"Proc\u00f3pio LCR","year":"2019","journal-title":"Saude Debate"},{"key":"ref19","doi-asserted-by":"crossref","first-page":"2386","DOI":"10.1111\/hex.13548","article-title":"Patients\u2019 experiences of, and engagement with, remote home monitoring services for COVID-19 patients: a rapid mixed-methods study","volume":"25","author":"Walton H","year":"2022","journal-title":"Health Expect"},{"issue":"12","key":"ref20","article-title":"Perfil dos pacientes com condi\u00e7\u00e3o p\u00f3s-Covid-19","volume":"24","author":"Bobrowec DCR","year":"2024","journal-title":"Rev Eletr Acervo Sa\u00fade"},{"key":"ref21","first-page":"27","article-title":"Modelo complexo Hospital de Cl\u00ednicas de gest\u00e3o de alta: concep\u00e7\u00e3o e implanta\u00e7\u00e3o","author":"Bernardino E","year":"2022","journal-title":"Cogitare Enferm"},{"issue":"6","key":"ref22","doi-asserted-by":"crossref","first-page":"349","DOI":"10.1093\/intqhc\/mzm042","article-title":"Consolidated criteria for reporting qualitative research (COREQ): a 32-item checklist for interviews and focus groups","volume":"19","author":"Tong A","year":"2007","journal-title":"Int J Qual Health Care"},{"key":"ref23","series-title":"Projeto de pesquisa","author":"Creswell JW.","year":"2007","edition":"2\u00aa"},{"key":"ref24","series-title":"Gest\u00e3o de alta ambulatorial: Inova\u00e7\u00e3o para a continuidade do cuidado","first-page":"165","author":"Bobrowec DCR.","year":"2024"},{"issue":"4","key":"ref25","first-page":"694","article-title":"A continuidade do cuidado na perspectiva do ser cuidado","volume":"19","author":"Freitas LFC","year":"2014","journal-title":"Cogitare Enferm"},{"key":"ref26","first-page":"e20180502","article-title":"Acesso versus continuidade do cuidado nos servi\u00e7os da rede de sa\u00fade: vivenciando possibilidades e contradi\u00e7\u00f5es","volume":"29","author":"Utzumi FC","year":"2020","journal-title":"Texto Contexto Enferm"},{"issue":"1","key":"ref27","doi-asserted-by":"crossref","first-page":"e310123","DOI":"10.1590\/s0103-73312021310123","article-title":"Acesso e continuidade assistencial na busca por cuidado em sa\u00fade: tecendo a rede entre encontros e entrela\u00e7os","volume":"31","author":"Acylino EM","year":"2021","journal-title":"Physis"},{"issue":"3","key":"ref28","doi-asserted-by":"crossref","first-page":"459","DOI":"10.1590\/S0034-71672010000300018","article-title":"Enfermeira de liga\u00e7\u00e3o: uma estrat\u00e9gia de integra\u00e7\u00e3o em rede","volume":"63","author":"Bernardino E","year":"2010","journal-title":"Rev Bras Enferm"},{"issue":"Suppl1","key":"ref29","doi-asserted-by":"crossref","first-page":"546","DOI":"10.1590\/0034-7167-2017-0490","article-title":"Nurse liaison: a strategy for counter-referral","volume":"71","author":"Ribas EN","year":"2018","journal-title":"Rev Bras Enferm"},{"key":"ref30","first-page":"e3162","article-title":"Liaison nurse activities at hospital discharge: a strategy for continuity of care","volume":"27","author":"Aued GK","year":"2019","journal-title":"Rev Latino-Am Enfermagem"},{"key":"ref31","doi-asserted-by":"crossref","first-page":"e20180332","DOI":"10.1590\/1980-265x-tce-2018-0332","article-title":"Continuity of hospital discharge care for primary health care: spanish practice","volume":"29","author":"Costa MFBNA","year":"2020","journal-title":"Texto Contexto Enferm"},{"key":"ref32","doi-asserted-by":"crossref","first-page":"e20210145","DOI":"10.1590\/1980-220x-reeusp-2021-0145","article-title":"Hospital-primary care articulation in care transition: both sides of the process","volume":"55","author":"Mauro AD","year":"2021","journal-title":"Rev Esc Enferm USP"},{"issue":"5","key":"ref33","doi-asserted-by":"crossref","first-page":"e20200530","DOI":"10.1590\/2177-9465-ean-2020-0530","article-title":"Pr\u00e1ticas de enfermeiros de um hospital universit\u00e1rio na continuidade do cuidado para a aten\u00e7\u00e3o prim\u00e1ria","volume":"25","author":"Oliveira LS","year":"2021","journal-title":"Esc Anna Nery"},{"key":"ref34","doi-asserted-by":"crossref","first-page":"e20220396","DOI":"10.1590\/2177-9465-ean-2022-0396pt","article-title":"Transi\u00e7\u00e3o do cuidado \u00e0 mulher no per\u00edodo puerperal na alta hospitalar","volume":"27","author":"Aued GK","year":"2023","journal-title":"Esc Anna Nery"},{"issue":"1","key":"ref35","doi-asserted-by":"crossref","first-page":"79","DOI":"10.21675\/2357-707X.2021.v12.n1.4048","article-title":"Enfermeiro de liga\u00e7\u00e3o de uma maternidade de risco habitual: dados de contrarrefer\u00eancias","volume":"12","author":"Silva OB","year":"2021","journal-title":"Enferm Foco"},{"issue":"2","key":"ref36","first-page":"248","article-title":"V\u00ednculo e comunica\u00e7\u00e3o no processo de trabalho de profissionais de sa\u00fade na aten\u00e7\u00e3o prim\u00e1ria \u00e0 sa\u00fade: uma revis\u00e3o integrativa","volume":"6","author":"Viana FDC","year":"2023","journal-title":"Rev Inters Encontro Cienc"},{"key":"ref37","doi-asserted-by":"crossref","first-page":"73154","DOI":"10.5216\/ree.v25.73154","article-title":"Contrarrefer\u00eancia: estrat\u00e9gia para continuidade do cuidado na sa\u00fade da mulher e rec\u00e9m-nato","volume":"25","author":"Lima LS","year":"2023","journal-title":"Rev Eletr Enferm"},{"key":"ref38","doi-asserted-by":"crossref","first-page":"e20200435","DOI":"10.1590\/2177-9465-ean-2020-0435","article-title":"Cuidados de transi\u00e7\u00e3o: an\u00e1lise do conceito na gest\u00e3o da alta hospitalar","volume":"26","author":"Bernardino E","year":"2022","journal-title":"Esc Anna Nery"},{"issue":"Supl 1","key":"ref39","doi-asserted-by":"crossref","first-page":"e0024678","DOI":"10.1590\/1981-7746-sol00246","article-title":"Trabalho em equipe: uma revisita ao conceito e a seus desdobramentos no trabalho interprofissional","volume":"18","author":"Peduzzi M","year":"2020","journal-title":"Trab Educ Sa\u00fade"},{"issue":"1","key":"ref40","first-page":"e2211","article-title":"Desaf\u00edos en la continuidad de cuidados para la pr\u00e1ctica profesional de enfermer\u00eda","volume":"22","author":"Garc\u00eda-Vivar C","year":"2022","journal-title":"Aquichan"}],"container-title":["Revista Brasileira de Enfermagem"],"original-title":["Modelo de gest\u00e3o de alta ambulatorial: estrat\u00e9gia para promover a continuidade do cuidado"],"link":[{"URL":"http:\/\/www.scielo.br\/scielo.php?script=sci_pdf&pid=S0034-71672026000100626&tlng=en","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,3,30]],"date-time":"2026-03-30T13:09:26Z","timestamp":1774876166000},"score":1,"resource":{"primary":{"URL":"http:\/\/www.scielo.br\/scielo.php?script=sci_arttext&pid=S0034-71672026000100626&tlng=en"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2026]]},"references-count":40,"alternative-id":["S0034-71672026000100626"],"URL":"https:\/\/doi.org\/10.1590\/0034-7167-2025-0221","relation":{"is-translation-of":[{"id-type":"doi","id":"10.1590\/0034-7167-2025-0221pt","asserted-by":"subject"},{"id-type":"doi","id":"10.1590\/0034-7167-2025-0221pt","asserted-by":"object"}]},"ISSN":["1984-0446","0034-7167"],"issn-type":[{"value":"1984-0446","type":"electronic"},{"value":"0034-7167","type":"print"}],"subject":[],"published":{"date-parts":[[2026]]},"article-number":"e20250221"}}