A gestão do processo de transição do cuidado entre o Serviço de Atenção Domiciliar e a Atenção Primária à Saúde

Abstract

Care transition is a strategy adopted worldwide to avoid the fragmentation of care experienced by users during their journey through the Health Care Network (HCN). This study had the general objective of analyzing the management of the Care Transition process between the Home Care Service and Primary Health Care. The specific objectives of this study were: to identify the understanding of health professionals and managers about Care Transition; to identify strategies and mechanisms for articulation in the Care Transition between the Home Care Service and Primary Health Care; to identify the weaknesses and potentialities of health professionals and managers in carrying out the Care Transition between the Home Care Service (HCS) and Primary Health Care (PHC) and describe strategies to promote the Transition of Care between the Home Care Service and Primary Health Care from the perspective of health professionals and managers. A single case study with a qualitative approach was conducted. The setting was the Barreiro Health Region, in the city of Belo Horizonte, Minas Gerais. The study had 26 participants, including professionals from family health teams, multidisciplinary home care team (MHCT) professionals and managers from local, central and regional health levels. Data were collected through semi-structured interviews between April and July 2024, submitted to Thematic Content Analysis and organized into four categories of analysis: “Transition of care from the perspective of health professionals and managers”; “Strategies for care transition between HCS and PHC”; “Articulation between HCS and PHC teams in care transition: potential and challenges”; and “Perspectives for care transition in the health network: need to implement and define new actions and strategies”. In the first category, the participants demonstrated clarity regarding the concept of transition of care, which was correlated with collaboration, knowledge sharing, and connection between services and professionals to provide comprehensive, safe, and qualified care. The second category described the strategies used for care transition in the daily work of the MHCT and the FHS team, including sending discharge summaries; discussing cases of greater care complexity; and holding a conversation circle between the MHCT and the FHS team. The third category exposed the potential and challenges faced by teams in care transition. This study revealed gaps in the organization and implementation of care transition between the HCS and PHC. As a technical product of this study, a technical report was prepared to be presented to the Municipal