{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,3,24]],"date-time":"2026-03-24T21:26:22Z","timestamp":1774387582231,"version":"3.50.1"},"reference-count":28,"publisher":"MDPI AG","issue":"22","license":[{"start":{"date-parts":[[2021,11,17]],"date-time":"2021-11-17T00:00:00Z","timestamp":1637107200000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["IJERPH"],"abstract":"<jats:p>In recent years, nurses have developed projects in the area of hospital to community transition. The objective of the present study was to analyze the transitional care offered to elderly people after they used emergency services and were discharged to return to the community. The action research method was chosen. The participants were nurses, elderly people 70 years old or older, and their caregivers. The study was carried out from October 2018 to August 2019. The data were collected by means of semi-structured interviews with the nurses, analysis of medical records, participatory observation, phone calls to the elderly people and caregivers, and team meetings. The qualitative data were submitted to Bardin\u2019s content analysis. Statistical treatment was carried out by applying SPSS version 23.0. The institution\u2019s research ethics committee approved the research. Only 31.4% of the sample experienced care continuity after discharge, and the rate of readmission to emergency services during the first 30 days after discharge was 33.4%. The referral letters lacked data on information provided to patients or caregivers, and nurses mentioned difficulties in communication between care levels, as well as obstacles to teamwork; they also mentioned that the lack of health policies and clinical rules to formalize transitional care between the hospital and the community perpetuated non-coordination of care between the two contexts. The low level of literacy of patients and their relatives are mentioned as a cause for not understanding the information regarding seeking primary health care services and handing the discharge letter. It was concluded that there is an urgent need to mobilize health teams toward action in the patients\u2019 process of returning home, and this factor must be taken into account in care planning.<\/jats:p>","DOI":"10.3390\/ijerph182212052","type":"journal-article","created":{"date-parts":[[2021,11,17]],"date-time":"2021-11-17T09:16:11Z","timestamp":1637140571000},"page":"12052","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":6,"title":["Transitional Care Management from Emergency Services to Communities: An Action Research Study"],"prefix":"10.3390","volume":"18","author":[{"given":"Jos\u00e9","family":"Batista","sequence":"first","affiliation":[{"name":"Vila Franca de Xira Hospital, 2600-009 Vila Franca de Xira, Portugal"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Carla Munhoz","family":"Pinheiro","sequence":"additional","affiliation":[{"name":"ACES Estu\u00e1rio do Tejo, 2630-242 Arruda dos Vinhos, Portugal"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Carla","family":"Madeira","sequence":"additional","affiliation":[{"name":"Vila Franca de Xira Hospital, 2600-009 Vila Franca de Xira, Portugal"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-2788-389X","authenticated-orcid":false,"given":"Pedro","family":"Gomes","sequence":"additional","affiliation":[{"name":"Portuguese Institute of Oncology, Nursing Research, Innovation and Development Centre of Lisbon, 1900-160 Lisbon, Portugal"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-1703-347X","authenticated-orcid":false,"given":"\u00d3scar Ramos","family":"Ferreira","sequence":"additional","affiliation":[{"name":"Nursing School of Lisbon, Nursing Research, Innovation and Development Centre of Lisbon (CIDNUR), 1900-160 Lisbon, Portugal"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-7417-1732","authenticated-orcid":false,"given":"Cristina Lavareda","family":"Baixinho","sequence":"additional","affiliation":[{"name":"Nursing School of Lisbon, Nursing Research, Innovation and Development Centre of Lisbon (CIDNUR), 1900-160 Lisbon, Portugal"},{"name":"Center for Innovative Care and Health Technology (ciTechCare), Polytechnic of Leiria, 2411-901 Leiria, Portugal"}],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"1968","published-online":{"date-parts":[[2021,11,17]]},"reference":[{"key":"ref_1","doi-asserted-by":"crossref","first-page":"73","DOI":"10.29352\/mill0205.07.00171","article-title":"Support and training of family caregivers: Nursing intervention program","volume":"2","author":"Melo","year":"2018","journal-title":"Millenium J. 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