Primary Health Care in transitional care of people with stroke.
Adriana Bitencourt Magagnin, Kenia Lara da Silva, Giane Zupellari Dos Santos Melo and 1 others
PMID 39082551WHAT IT FOUND
PHC teams and caregivers saw stroke follow-up after discharge as needing continuous monitoring, family education and nursing support.
High workload and pandemic gaps made that continuity hard.
Key findings
01PHC continuity and secondary prevention were seen as necessary, but high spontaneous demand made longitudinal care difficult.
02Family inclusion in care planning was important, and PHC nurses were described as comprehensive, attentive care managers who build bonds with people and families.
03Community health workers were described as a bridge between families and services, but shortage, coverage gaps and other tasks limited their role.
STILL TO COME
How it was doneWhat they foundWhat it means for RNs
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What it does not show
The study was done in one municipality in southern Brazil that is recognised for stroke care and has a multidisciplinary residency program, so its arrangements may not match other services. Data were collected during the COVID-19 pandemic, which affected team routines and group activities, so the barriers described may differ outside that period. The findings are views from professionals and family caregivers, not patient outcomes or a tested effect of a transitional care programme. Some PHC professionals had less than two years in the unit, and participants reported high workload and limited knowledge of the Line of Care, which may shape what they could observe.
The easy way to misread this
Do not read this as proof that PHC transitional care improves care for people with stroke. It reports views and service experiences from one Brazilian municipality, not results for people with stroke.