Logical Model in the Transition of Care for People With Stroke From the Perspective of Comprehensive Care

Bibliographic Data

ID21433481
AuthorsAdriana Bitencourt Magagnin (0000-0002-1607-9484, Faculdade IELUSC, Brasil), Ingeborg Heidemann (0000-0001-6216-1633, Universidade Federal de Santa Catarina), Michelle Kuntz Durand (0000-0003-3660-6859, Universidade Federal de Santa Catarina), Ana Flávia dos Santos Almeida (0009-0003-7296-6533, Universidade Federal de Santa Catarina), Laura Tais Loureiro Simas (0000-0002-9052-7740, Secretaria Municipal de Santa Maria, Brasil), Rosilda Veríssimo Silva (0000-0002-1241-8282, Faculdade IELUSC, Brasil), Janaina Medeiros De Souza (0000-0001-8645-9215, Universidade Federal de Santa Catarina), Aldalice Aguiar de Souza (0000-0002-3002-4578, Universidade do Estado do Amazonas)
Year2025
Volume34
Publication date2025-01-01
Peer ReviewedYes
Open AccessYes
TypeARTICLE
VenueTexto & Contexto - Enfermagem (JOURNAL)
Journal identifiersISSN: 0104-0707 • E-ISSN: 1980-265X
PublisherFapUNIFESP (SciELO) (PUBLISHER)
DOI10.1590/1980-265x-tce-2024-0254en
LanguageEN
References cited16

Objective: to propose a logical model for the transition of care for people with stroke post-hospital discharge, grounded in comprehensive care. Method: a single case study with integrated analysis units, employing a qualitative approach and supported by the principles of comprehensiveness and care transition. Data collection took place from September 2021 to February 2022, in a municipality in northern Santa Catarina, within the Health Care Network, Stroke Care Unit, Primary Care Units, and households. Evidence was derived from interviews, document analysis, and non-participant observation. Data organization and coding were performed using the ATLAS.ti® software. The analytical technique involved constructing a logical model, which combines empirically observed and theoretical events. Results: five phases were delineated for the appropriate transition of care: a structured Stroke Care Pathway with trained teams; intra-hospital actions to prepare for discharge and involve caregivers; coordination between services; primary care engagement to ensure continuity of care; and the involvement of support services. Conclusion: although the study focuses on the transition of care between the hospital setting and primary care, the adequate continuity of care depends on a multitude of actors and coordinated actions. Considering the elements that facilitate these transitions is essential for building effective care pathways. Identifying and defining the key actions at each stage of the care journey guide teams in refining their practices and ensuring that care is comprehensive and efficient

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