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Establishing a link between tertiary hospital and Primary Healthcare Units: real project: redesigning hospital discharge


Introduction: Preventable readmission to hospital generates costs to the health system (SUS), beside causing higher social suffering to the patient. The Rate of Readmission is being used as an indicator of strategy in private health-insurances and international health systems. The optimization of the hierarchy of integrated health assistance proposed by the Brazilian health system SUS can reduce the Rate of Readmission. Aims: The project proposes the application of a systematization of the transition of the health assistance of patients admitted in the tertiary hospital to the primary health unit at the moment of discharge from hospital. Methods: Patients at discharge from the university hospital HCFMB will be randomized to 2 groups. Patients and caregivers of the Intervention Group will receive standardized orientations of follow-up and signs of alert at pre-discharge, elaborated by the specialists in accordance to their disease. The commission of discharge will check the reception and full understanding of the information by the patient or caregiver at the moment of discharge, as well as the attendance of return visits at the primary care center, the correct use of medications and the complementary orientations at follow-up. The patients of the Control Group will receive traditional orientations of discharge without standardized protocols of orientations nor supervision of integration of follow-up at the primary care center. All patients will have a follow-up of 6 months after hospital discharge. Patient´s absenteeism at primary care units, number of not scheduled visits at any health unit ant the rate of readmission to hospital will be compared for the two groups. Impact of each action will be evaluated for the listed outcomes. (AU)

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