Introduction

The Unified Health System (SUS) is structured under the logic of operating in Health Care Networks (HCN) that constitute organizational arrangements of services and health actions of different technological densities, aiming to manage care flows and enable comprehensive health care. This logic aims to overcome the fragmentation of care and ensure continuity of care at all levels of care.(¹)

The network of Federal University Hospitals (FUHs) is made up of 51 hospitals linked to 36 federal universities, which stand out as a medium and high complexity reference for HCN in all regions of the country. Furthermore, they play an important role in training health professionals and supporting teaching, research and extension in the educational institutions to which they are linked.(²,³)

The need to organize health services into networks arose in light of the demographic and epidemiological transition that the world has faced in recent decades, which has resulted in an increase in the elderly population and people with Chronic Non-Communicable Diseases (NCDs). This reality represents a major challenge for health systems, as the course of these diseases is long, and signs and symptoms can manifest themselves recurrently, demanding the need to maintain health, prevent complications, avoid new hospitalizations and ensure continuity of care at all levels of care.(¹,⁴)

Continuity of care can be understood as the connection and/or succession of care and services needed by patients throughout their flow in the HCN. In several countries around the world, such as the United States of America, Canada, the United Kingdom, among others, continuity of care stands out due to the benefits it presents. Among these, we highlight the improvement of patient satisfaction, cost reduction and adoption of actions that prevent readmissions after hospital discharge.(⁵,⁶)

Studies on continuity of care in Brazil have focused on discussing the implementation of hospital discharge management offices/services, referral and counter-referral strategies, and assessment of the quality of care transition.(⁷) Consolidation of continuity of care as a management and Clinical practice in Brazilian hospital institutions is still influenced by regional factors, health policy demands and structural conditions of services. Therefore, studies to identify actions and strategies aimed at improving continuity of care in different contexts across the country are important to disseminate experiences that can serve as a reference for other services.

Based on the above, the present study aimed to identify continuity of care actions carried out by Federal University Hospitals in Brazil.

Methods

This is a descriptive and exploratory research of a documentary nature, with a quantitative approach, carried out from the website of the Brazilian Hospital Services Company (EBSERH), responsible for managing FUHs since 2011, when it assumed the role of coordination and evaluation of activities performed by hospitals. Furthermore, it provides technical support in the development of instruments that help improve the management and distribution of hospital resources.(³)

The data was collected by researchers in January 2023. Data collection was based on news published on the website of the Brazilian Hospital Services Company (EBSERH) in text format. To this end, the use of the term “Continuity of Care” was established as a search parameter, with no time limit. Although there is a lack of consensus on the term in international literature, it was decided to use it to map a greater number of potential news articles, since national studies have demonstrated a preference for adopting this nomenclature.(¹,⁶-¹⁴)

The following information was extracted and organized in a spreadsheet using Microsoft Excel® software: year of publication, region and Brazilian state in which the UH is located, patient profile and nursing participation. It is worth noting that the extraction and eligibility of the news was initially evaluated by two doctors with expertise in the topic of this study and a postgraduate student, in order to guarantee compliance with the inclusion criteria. In addition to these, as the research is the result of a dissertation, the three members of the committee contributed to the evaluation.

The data were analyzed according to the dimensions of continuity of care: Relational, Informational and Managerial. The relational dimension concerns the connection developed over time and place through the patient-professional relationship. The informational dimension encompasses the availability or sharing of information relevant to care involving patients/families and professionals, as well as between the various professionals who provide care to the patient. The managerial dimension refers to the ability to coordinate, link and sequence care, its attributes overlap with those of the other two dimensions.(⁸)

To count absolute and relative frequency, each news article was considered as a unit of analysis, characterized by year of publication, geographic macro-region and state, in relation to the focus of the news. In order to give visibility to the specificity of each one, no grouping or categorization was done, they were all listed according to the dimension of continuity of care they approach.

As it is a public database, with wide access, the project did not need to go through a Research Ethics Committee.

Results

70 news items were found, of which 29 were excluded because they were not related to the theme proposed in this study; in cases of repetition, they were considered only once. The flowchart in figure 1 presents a summary of the news selection process.

The first news was identifeied in 2015. However, the majority was published in 2021 and 2022. The Northeast region stood out with the highest percentage. At the state level, Minas Gerais recorded the highest number of news articles. The largest percentage of news did not specify the user profile, but the maternal and child audience was highlighted. Regarding nursing participation, 41.5% of the actions were directly related to the profession’s performance, as shown in table 1.

When analyzing the content of the news, they were distributed and listed according to the three dimensions that constitute the continuity of care: Managerial, Relational and Informational, with the managerial dimension presenting the highest frequency of news, followed by the relational and informational dimensions, as presented in chart 1.

In the Management dimension, actions to promote continuity of care focused on the implementation of care integration services and home care services, care for patients diagnosed with Covid-19, women, especially during pregnancy and the postpartum period and/ or newborns and children, hospital discharge management, and multidisciplinary meetings. In the Relational dimension, the main actions focused on caring for patients in palliative care, attention to the indigenous population, and specialized outpatient care for people with cancer. In relation to the Informational dimension, the news conveys actions aimed at qualifying and computerizing care records, adopting protocols and sharing cases.

Discussion

The study identified continuity of care actions in 19 University Hospitals managed by EBSERH. The data showed the growth in the broadcasting of news actions over the last 5 years, demonstrating the growing demand for interest in relation to the topic. Such growth may be related to the demographic and epidemiological transition of the population, given the pattern of aging and increase of life expectancy that demand a greater supply of services and care for chronic health conditions.(¹,⁹)

It is noteworthy that in Brazil, NCDs represent a major challenge for public health, both due to morbidity and mortality rates and economic issues. Because the consequences of these diseases lead to an increase in hospital admissions, prolonged drug treatments and the need for rehabilitation, culminating in an increase in spending on highly complex cases.(¹⁰,¹¹)

In relation to Brazil’s macro-regions, the Northeast has the largest number of identified actions. Within the EBSERH network, the region has 14 UHs, the largest number in the country. Even so, this region faces historical issues of difficulties in accessing health services.(²,¹²)

The highlight for the Northeast reflects the performance of hospitals in focusing on continuity of care strategies, aiming to improve access to healthcare for the Northeastern population. The North region appears with the lowest percentage of news about continuity of care actions. This region has a low concentration of professionals and experts in the health field, the lowest Human Development Index (HDI) in the country and large geographic barriers that make access to certain health services difficult in relation to other regions of the country.(¹³) It should also be added that this region has only 3 UHs, which may justify the low concentration of news obtained in the North.(³)

As for the target audience for continuity of care actions, 46.4% of the news did not specify it. This data may reflect the search by UHs to promote continuity of care for all users of the health system based on the multiple needs of the clientele served. Measures adopted to combat the Covid-19 pandemic, such as the cancellation and reduction of outpatient care and elective procedures, may also have stimulated services and/or continuity of care actions for a wider clientele.(²)

Next, 14.6% of UHs’ continuity actions refer to women’s and children’s health. Among the factors that can influence the growing number of continuity of care actions by UHs aimed at women, the incidence and mortality from cancer in the female population stands out, especially breast and cervical cancer.(¹⁴,¹⁵) In this reality, the adoption of continuity of care actions, focusing on specialized outpatient care for women with cancer implemented by UHs in the country, is of utmost importance for monitoring and timely treatment of this population.

In relation to the child, the actions identified highlight the continuity of care during the postpartum period with a focus on encouraging breastfeeding through the restructuring of exclusive physical space for breastfeeding. It is noteworthy that exclusive breastfeeding until six months of age is a protective factor for the child’s general health, reducing child morbidity and mortality associated with malnutrition and obesity.(¹⁵,¹⁶)

Patients in palliative care were the second group highlighted in the UHs’ continuity of care actions, normally related to the demands of individualized and humanized care. This group requires special care to improve quality of life through interventions to prevent injuries, relieve and treat pain and physical, social, psychological and spiritual symptoms relevant to the health condition.(¹⁷)

Continuity of care actions aimed at patients affected by Covid-19 are also worth highlighting. Even though they were not numerically significant, they indicate the search for HUs to implement services aimed at caring for patients with persistent and often disabling symptoms after SARS-CoV-2 infection.(¹⁸,¹⁹)

Nursing participation in care continuity actions carried out by UHs was significant (41.5%), although this information was not specified in most publications. The articulation between clinical and managerial nursing performance allows the provision of care focused on individual and collective needs for prevention, promotion and rehabilitation, as well as developing responses to the challenges of health services regardless of the scenarios and contexts of operation. Furthermore, the leadership position of nurses in multidisciplinary and interdisciplinary teams stands out, which favors the expansion of continuity of care in services.(⁶,²⁰,²¹)

When distributing the actions reported by the HUs in the three dimensions of continuity of care, the largest number was allocated to the Management dimension with a focus on home care/assistance and care for patients diagnosed with Covid-19, promoting continuity of care for patients after hospital discharge. This dimension directs the provision of care in a connected and coordinated manner through interaction between different professionals, services and health institutions in an integrated and articulated manner, using protocols and care management plans related to the needs presented by the patient.(²²)

The positive impacts of home care programs for the continuity of care are highlighted, especially for individuals with multiple comorbidities and the elderly, as they require longer hospitalization, financial and human resources from health institutions.(²³) The implementation of services and processes driven by the Covid-19 pandemic, with emphasis on telecare, contributed to facilitating access to health services and specialized care for the population affected by the disease during the pandemic period.(²⁴)

Within the scope of the Relational dimension, permanent education and health education actions aimed at continuing care for individuals with chronic conditions stand out. Continuing education activities aimed at continuity of care should focus on pathophysiological and clinical aspects, with special attention to elements of care transition planning, involving the family and caregivers based on the patient’s preferences, while addressing the main barriers to be overcome.(²⁵) Health education activities for patients with chronic conditions promote self-care and can reduce the use of hospital services, control the incidence of acute conditions and improve the continuity of care in primary health care and at home.(²⁶,²⁷)

Still in the Relational dimension, an action aimed at overcoming linguistic barriers was identified, referring to the difficulties faced by individuals in understanding a certain language or dialect, whether in written or spoken form, being configured as an important social determinant of health.(²⁸) The relationship between continuity of care and linguistic agreement between professionals and users has shown the potential to reduce adverse effects and hospital readmission.(²⁹) Considering the Brazilian territorial extension and the existence of indigenous populations with broad cultural diversity, the adoption of actions aimed at Facilitating communication between indigenous patients and health professionals strengthens the continuity of care in the community and at home.(³⁰)

Finally, the Informational dimension brought actions to improve the management of patient care information with the use of systems and protocols and case management. This dimension allows obtaining and sharing information about the patient’s conduct, recommendations, daily life situation and laboratory results. Therefore, there is a need for user information to be recorded in a way that can be recognized at different points that connect previous care to the current and future.(³¹) In case management, people are identified within the service structure and characterized by the specificities of their current or future care, including the connection and synchronization of services, the fulfillment of multidisciplinary and patient-centered objectives, facilitating continuity of care.(³²)

In this dimension of continuity of care, action that addresses hospital discharge summary for primary care also stands out. Patient guidance at hospital discharge is essential to improve their clinical condition after hospitalization. In the period after hospital discharge, the user may experience vulnerability and risk of worsening of their clinical condition, justifying the need to record their health information correctly to facilitate the transition process and continuity of care.(³³)

It is crucial that there is effective coordination between HUs and other health services to advance the continuity of care. The organization of work in the micropolitical dimension of health care production can be strengthened with strategies and tools such as safe discharge, clinic management, case discussion, nurse liaison, regulatory complexes and continuing education.(²²)

Although research demonstrates efforts to design studies and strategies that contribute to consolidating the transition and continuity of care after hospital discharge, efforts are still needed to identify, develop and implement techniques that strengthen continuity, especially in SUS.(⁷)

The data collection source used can be considered a limitation of this study. The information conveyed by the EBSERH website may not represent the concrete actions of continuity of care carried out in the UHs, but what gains greater notoriety for dissemination. Furthermore, it is worth noting that university hospitals represent a small portion of Brazilian hospitals, making further investigations in hospitals with other legal regimes and/or management models necessary.

Conclusion

UHs have showed increasing investment attitudes for the development of actions to continue patient care, especially in the last five years. In the Management dimension, the main focus was home care/assistance and care for patients diagnosed with Covid-19. In the Relational dimension, permanent education and health education actions and overcoming language barriers stand out. The improvement of care information management was highlighted in the Informational dimension through the use of systems, protocols and case management.

References

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