Continuity of care: actions carried out in Brazilian university hospitals

M’batna, Alberto João; Cechinel-Peiter, Caroline; Costa, Maria Fernanda Baeta Neves Alonso da; Cunha, Carlos Leonardo Figueiredo; Debétio, Juanah Oliveira; Lemos, Messias; Lanzoni, Gabriela Marcellino de Melo; Santos, José Luís Guedes dos

doi:10.37689/acta-ape/2025AO0003391

Brazil

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Original Article • Acta Paul Enferm 38 • 2025 • https://doi.org/10.37689/acta-ape/2025AO0003391i linkcopy

Continuity of care: actions carried out in Brazilian university hospitals

Authorship SCIMAGO INSTITUTIONS RANKINGS

Abstract

Objective To identify care actions of continuity in federal university hospitals in Brazil.

Methods This is descriptive and exploratory research of a documentary nature, with a quantitative approach. The data was collected in January 2023 directly from the Brazilian Hospital Services Company website. Data analysis occurred using simple descriptive statistics.

Results The sample consisted of 41 news items, the majority (22%) published in 2021, by hospitals in the Northeast region (34.1%) and with women and children as the main target audience. Nursing participation was specified in 41.5% of the actions. The main actions identified were the implementation of home care/assistance services, continuing education and health education actions and the implementation of systems, protocols and case management tools aimed at hospital discharge.

Conclusion There is a growing interest among Brazilian university hospitals in developing actions for continuity of care, mainly related to the management dimension.

Variable	n(%)
Year
2015	1(2.4)
2017	3(7.3)
2018	8(19.5)
2019	8(19.5)
2020	4(9.8)
2021	9(22)
2022	8(19.5)
Region
Northest	14(34.1)
Southest	10(24.5)
South	8(19.5)
Midwest	8(19.5)
North	1(2.4)
State in Brazil
Minas Gerais	7(17.2)
Sergipe	6(14.6)
Pernambuco	5(12.2)
Paraná	4(9.8)
Rio Grande do Sul	4(9.8)
Goiás	3(7.3)
Mato Grosso do Sul	3(7.3)
Distrito Federal	2(4.9)
Rio de Janeiro	2(4.9)
Amazonas	1(2.4)
Bahia	1(2.4)
Maranhão	1(2.4)
Paraíba	1(2.4)
São Paulo	1(2.4)
Target Audience
Not specified	19(46.4)
Woman and child	6(14.6)
Patients in palliative care	4(9.8)
Patients with wounds/burns	2(4.9)
Patient with mental suffering/disorder	2(4.9)
Patients with Covid-19	3(7.3)
Indigenous people	2(4.9)
People with complex health issues	1(2.4)
Patients with cancer	1(2.4)
Patients with HIV/AIDS	1(2.4)
Nursing participation
Not specified	24(58.5)
Yes	17(41.5)

Managerial Dimension (n=22; 53.6%)
1. Multidisciplinary meeting
2. Adequacy and functioning of hospital admissions and discharges according to referral and counter-referral criteria
3. Scientific Event - II Symposium on Home Care Service
4. Qualification of the House for Pregnant Women, Babies and Postpartum Women for continuity of care
5. Agreement on assistance flows
6. Unique Therapeutic Project for humanization
7. Better at Home Program
8. Scientific Event - articulation of institutions for Continuity of Care
9. Lectures/Visits to identify patients at risk of suicide
10. Breastfeeding Clinic - restructuring of the physical space
11. Humanization Working Group
12. Discharge Management Program
13. Transitional Care Support Unit
14. Post-Covid Rehabilitation Unit
15. Implementation of teleservices to care for patients with Covid-19 and other demands
16. Institutional meeting aimed at continuing service to users within the local Health Care Network (HCN).
17. Skin Care Nursing Working Group for Home Care Guidance
18. Health Care Regulation Sector
19. Implementation of teleservice to guide patients, prescribe or interact with colleagues to discuss patient diagnosis and therapy.
20. Care Regulation Unit for continuity of care and responsible hospital discharge
21. Advanced Multidisciplinary Post-Covid-19 Care Center
22. Advice for continuity of care
Relational Dimension (n=12; 29.2%)
1. Inclusion of an interpreter in health care for the indigenous population
2. Joint effort to offer complete oral health treatment to indigenous children
3. Training to care for patients living with HIV/AIDS
4. Scientific event on assistance in palliative care
5. Educational actions for professionals and women about the importance of breastfeeding
6. Specialized outpatient follow-up - Oncology Nursing Navigation Outpatient Clinic
7. Multidisciplinary Sexuality Outpatient Clinic for women with gynecological cancer
8. Multidisciplinary course/lectures in palliative care
9. Training course for hospital professionals for procedures that allow the discharge of palliative patients
10. Scientific Event - Quality and Patient Safety Forum
11. Conversation circle about suicide prevention
12. Events/training to encourage the building of bonds between professionals and users
Informational Dimension (n=7; 17.0%)
1. Development of an educational video to improve care records
2. Restructuring of the Medical and Statistical Archive Service
3. Carrying out a hospital discharge summary for primary care
4. Implementation of ISBAR (Introduction, Situation, Background, Assessment, Recommendation)
5. Implementation of a new computerized system for clinical records
6. Multidisciplinary meeting to discuss cases
7. Seminar on the importance of the quality of records in the medical record

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