6th Edition of World Nursing Science Conference 2026

Abstract

Background: Hospital discharge represents a critical transition in the care pathway, particularly for older adults. Fragmented communication between hospital and Primary Health Care (PHC), insufficient preparation of patients and caregivers, and the absence of structured post-discharge follow-up may compromise continuity and patient safety. Within integrated healthcare systems, PHC nurses are strategically positioned to bridge hospital and community care and support patients and families during this vulnerable period.
Aim: To describe the development of Alta Segura (Safe Discharge), a nurse-led quality improvement project designed to establish a structured model of post-hospital discharge follow-up for older adults in PHC, strengthening continuity, care integration, and safe transitions from hospital to home.
Intervention: Alta Segura was developed in a Portuguese PHC setting within an integrated healthcare organization. The model targets adults aged 65 years or older discharged from hospital to their homes and establishes proactive nursing contact within the first three days following discharge, primarily by telephone or video call. This initial contact enables a structured assessm ent of individual needs and supports the definition of an individualized care plan. Key areas include medication reconciliation, recognition of warning signs, therapeutic education, self-care needs, nutrition, home care, available community resources, and caregiver preparedness and support. When additional needs are identified, patients are referred to their family healthcare team for appropriate intervention, including home visits when required.
The model also addresses organizational and communication barriers across care settings by reviewing hospital-to-PHC discharge information pathways and promoting timely access to discharge information. Process indicators include electronic receipt of hospital discharge information, completion of nursing assessment within three days, referral according to identified needs, and caregiver preparedness to support self-care. Patient and caregiver satisfaction and 30-day hospital readmission were defined as outcome indicators for future evaluation.
Conclusion: Alta Segura proposes a structured, nurse-led approach in which post-discharge follow-up becomes an active component of integrated care rather than a reactive response to emerging needs. By combining early contact, individualized assessment, therapeutic education, caregiver support, and coordination across healthcare settings, the model reinforces the role of PHC nurses as facilitators of continuity and safe transitions from hospital to home. Future evaluation will assess its contribution to care processes, patient and caregiver experience, and hospital readmissions.
Keywords: Transitional Care; Continuity of Patient Care; Primary Health Care; Nursing; Patient Discharge; Integrated Health Care; Patient Safety.