[Discharge Plan: A Care Tool - Chronic Disease DyadPlano de saída: ferramenta de cuidados - diade com doença crónica].

Introduction: The WHO reports an increase in chronic non-communicable diseases. Given the complexity of these diseases, patients are constantly hospitalized; therefore, it is necessary to strengthen the competence of both patients and caregivers at home to take care of the disease using the program "discharge plan."

Objective: To determine the change in care competency following the implementation of the tool "discharge plan" in a second-level care facility for in-home care of the chronically ill person and family caregiver dyad.

Materials and methods: Quantitative, quasi-experimental study, with pre-test and post-test design, using the "Characterization of the patient-caregiver dyad" form and the "CUIDAR" instrument. The population consisted of 62 dyads. Non-probabilistic convenience sampling was used. Pre- and post-delta was calculated, and paired Student t-test was used for comparison.

Results: The "discharge plan" program increased the patients' dimensions of Knowledge by a delta of 3.2, Uniqueness by 3.0, and total care competency by 10.3. Family caregivers'competencies improved in the dimensions of Knowledge by a delta of 3.34, Uniqueness by 1.5, Enjoyment by 1.7, and Reciprocity relationship by 1.61, for a total competency score of 9.2.

Discussion and conclusions: These findings suggest that the discharge plan program must be strengthened during hospitalization and discharge to improve the homecare competency of chronically ill patients and their family caregivers.