Abstract
The overall improvement in living conditions has led, in recent decades in Portugal, to a progressive increase in life expectancy. Unfortunately, it didn´t came with more health or quality since, along with the aging of our population, we are witnessing to an increase in chronic non-communicable diseases (NCDs) and functional dependence and disability that reflects in increased needs for health care.
In the coming years, Portugal will be one of the European countries in which the pressure of population aging will be felt the most regarding the increase in demand for health units, which will certainly have a marked impact on our health system.
Convinced that one of the processes that will suffer is hospital discharge surely postponement due to the increased number of frail elderly and knowing that the population over 65 years of age represents about 75% of the patients hospitalized in the Internal Medicine Units of our hospital, we felt the need to develop and implement early and standardized hospital discharge planning structured by multidisciplinary teams. It is intended that a safe and adequate transition of care is ensured from admission to discharge, through an integrative approach to hospital and community health care that obliges to the development of efficient communication channels within hospitals and the different levels of care.
To test this strategy, we carried out a prospective study, starting in January 2025, which uses a methodology that privileges action-research in the application of a clinical signaling instrument to Social Work (SWAAT); assessment of functional capacity at admission and after discharge (Barthel); assessment of the Complexity of Social Intervention (SWIC) and evaluating the patient's perception of the quality and satisfaction that constituted his/her discharge planning process (PREPARED).
Our aim is to build a program that improves clinical practice with the involvement of the various professionals caring hospitalized patients, in a structured interdisciplinary approach and with effective health gains for patient and family, shortening the length of stay in the hospital and access to integrative care guaranteed by communication channels between the different levels of care.