Adriana Bitencourt Magagnin, Kenia Lara da Silva, Giane Zupellari Dos Santos Melo, Ivonete Teresinha Schulter Buss Heidemann
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Primary Health Care in transitional care of people with stroke.
Objectives: to understand the role of Primary Health Care teams in caring for people with stroke after hospital discharge.
Methods: single case study, with integrated units of analysis, with a qualitative approach. Data triangulation occurred through interviews with professionals and family caregivers involved in transition of care, in addition to direct observations in rounds and document analysis. For the analyses, the analytical strategies of theoretical propositions and construction of explanations were used, with the help of ATLAS.ti®.
Results: the importance of counter-referral, the role of community health workers and the multidisciplinary team, health promotion, secondary prevention, home visits as a visceral attribute and nurses as care managers are evident.
Final considerations: the high demand on teams and the Social Determinants of Health interfere with adequate continuity of care. Transitional care programs that enable continuity of care are recommended.
期刊介绍：
The Revista Brasileira de Enfermagem created in 1932, March 20 is the official publication of the Associação Brasileira de Enfermagem (Brazilian Nursing Association) has as purpose to disseminate the scientific production from different nursing interest areas of knowledge, including those which express the political project of the Association. The Revista Brasileira de Enfermagem is the oldest journal of the Brazilian nursing. Its first title was "Annaes de Enfermagem" from 1932 to 1941, being entitled Anais de Enfermagem" until 1955, when its title was changed to the current.
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