| 1 - All staff involved in transitional care have received education regarding transitional care from hospital to home for older people. (10 of 10 samples taken) |
Nurses
Baseline audit: 10
Follow-up audit: 08 |
A questionnaire sent by Survey Monkey and Google Platform (form).
Question: have you received training on transitional care in the past six months?
It will be considered compliant if professional answers yes. |
2 - Patients/caregivers have received education regarding self-management interventions. (7 of 7
samples taken) |
Older people or caregivers/family members admitted to surgical clinic
Baseline audit: 07
Follow-up audit: 04 |
Interview with older person, caregiver/family:
Question: did you receive education about self-care at hospital discharge?
Yes ( )
No ( )
The criterion will be considered fulfilled when older people, caregivers/family members answer affirmatively. |
| 3 - An individualized discharge plan has been documented for all patients transitioning from hospital to home. (7 of 7 samples taken) |
Medical records of older patients admitted to surgical clinic.
Baseline audit: 07
Follow-up audit: 04 |
Was a discharge plan documented in nursing progress notes for hospital to home transition?
Yes ( )
No ( )
The criterion will be considered fulfilled when discharge is recorded in the patient's medical record. |
| 4 - Patients/caregivers have been involved in the discharge planning process. (7 of 7 samples taken) |
Older people or caregiver/family member admitted to the surgical clinic.
Baseline audit: 07
Follow-up audit: 04 |
Interview: Readiness for Hospital Discharge Scale adapted(15). |
| 5 - Transitional care services have been coordinated between the hospital and community setting. (7 of 7 samples taken) |
Patient system
(Computerized System)
Baseline audit: 07
Follow-up audit: 04 |
Check whether the return appointment was made at the HU-USP's outpatient clinic, after hospital discharge, in the hospital's computerized system.
Yes ( )
No ( )
It will be considered compliant if there is in the scheduling system the schedule of the return with medical or nursing staff. |
| 6 - Patient care needs have been communicated between the hospital and community healthcare providers. (7 of 7 samples taken) |
Medical records of older patients admitted to surgical clinic.
Baseline audit: 07
Follow-up audit: 04 |
The needs for patient care are documented in nursing progress notes at discharge.
Yes ( )
No ( )
The criterion will be considered fulfilled if there is medical record registry. |
| 7 - Post discharge follow-up has occurred. (7 of 7 samples taken) |
Patient System
(Computerized System)
Baseline audit: 07
Follow-up audit: 04 |
Check in the computerized patient system if there was an outpatient nursing and/or physician return.
Yes ( )
No ( )
The criterion will be considered fulfilled if a patient returned at the scheduled outpatient appointment. |
| 8 - A multifaceted, approach is used for transitioning older people from hospital to home (e.g. may include telephone follow-up, home-based exercise programs, patient-centered discharge instruction) (7 of 7 samples taken). |
Older people or caregivers/family members admitted to the surgical clinic
Baseline audit: 07
Follow-up audit: 04 |
Interview with older people
Question: did you receive guidance on general care, information leaflets, demonstration/participation in procedures, return to the outpatient clinic, medical prescription (medication use).
Yes ( )
No ( )
The criterion will be considered fulfilled if older people or caregivers/family members answer yes |
Transitional care from hospital to home for older people: implementation of best practices
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