4397en

Diani de Oliveira Machado¹, Flávia Moraes Silva Flávia², Sati Jaber Mahmud³, Fernanda Laís Fengler¹, Lisiane Manganelli Girardi Paskulin¹

¹Federal University of Rio Grande do Sul
²Univates
³Conceição Hospital Group

ABSTRACT
Aim: To characterize the profile of adult patients of the Home Care Program (HCP) of the Conceição Hospital Group (CHG) and their demands for nursing support.
Method: This is a descriptive exploratory study incorporating retrospective data collection.
Results: Of the 826 adult patients supported by HCP/CHG (median follow-up of 21 days and five visits), the majority were female (53.9%) and over 65 years of age (50.6%). The main pathologies were thromboembolism (10.9%) and cerebrovascular accident (10.3%). The main demands in terms of nursing care were dressing (32.4%) and monitoring blood glucose levels (19.7%).
Discussion: The prevalence of elderly in the sample can be explained by population aging. This data, together with pathologies associated with greater physical dependence, can justify the need for specific nursing care.
Conclusion: The characterization of patients can contribute to the evaluation of the complexity of home care and provide better guidance in terms of care in residences.
Descriptors: Home Care Services; Nursing Care; Epidemiology.

The aging population and the epidemiological transition gives rise to different social problems and the changing needs in terms of health care⁽¹⁾, bringing challenges when it comes to guiding the search for forms of care that may provide coverage for the current scenario. The forms of care focused on integrality include the basic, the specialized and the hospital forms. The ways of providing care in the home arise in this context, giving rise to Home Care (HC) services⁽²⁾.

HC is a modality of care with expertise in monitoring the health of individuals, in order to promote, maintain or restore it through actions undertaken in the domestic situation with regard to health promotion and prevention, as well as the treatment of diseases⁽¹⁾. Reducing costs by discharging patients is one of the organizational aspects of HC ⁽¹⁾. However, the possibility of reducing the risk of exposure to hospital infections and allowing the recovery of the patient in his own home, within his family and in his social reality, denotes the real contribution of this modality as part of the National Unified Health (NHS).

The first experiences with HC in Brazil involve the Emergency Medical Home Care Service (EMHCS). This was founded in 1949 and is linked to the Ministry of Labour. Since 1960, the HC services went through an expansion, involving care aimed at patients who suffered from acquired immunodeficiency syndrome, skin lesions, severe neurological disorders, and patients who needed palliative care and treatment of infections, as well as the dehospitalization of patients following long hospital stays⁽³⁾. HC was established in 2002 as the modality of care in the NUHS by adding a chapter and an article to Law 8080/90⁽⁴⁾. In 2006, the Board of Resolution of the National Health Surveillance Agency (NHSA) was created in order to guide the functioning and structuring of the services that provide HC⁽⁵⁾. Five years later, the Ministry of Health implemented the service Better at Home, based on Decree 2527 of October 2011⁽⁶⁾ with the aim of regulating HC in full within various modalities of care within the NUHS.

The Home Care Program of the Conceição Hospital Group (HCP/CHG) was implemented in Porto Alegre (Rio Grande do Sul) in 2004. Patients supported by HCP live in the northern region of the city (catchment area = 400,000 inhabitants) and are referred from inpatient units or by the emergency services of the four hospitals of the Group. The HCP/CHG operates through home visits involving minimum core teams, composed of physicians, nurses and nursing technicians, and it is supported by a physiotherapist, social worker and nutritionist. The aim of HCP/CHG is to support patients in their homes in order to provide the completion of health treatment, reduce overcrowding in emergency facilities, perform the transition from hospital care, and to guide and assist patients and families in care production. The monitoring period is thirty days on average. After clinical stabilization and the structuring of the care plan, the patient is discharged from the Program and is relinked to the basic referral healthcare unit.

Considering the diagnostic needs of the patients and their demands for nursing health services, this study aimed to characterize the profile of adult patients supported by HCP/CHG and to assess their demands for nursing care.

METHOD

This is a descriptive exploratory study, in which a retrospective data collection was extracted from a convenience sample consisting of all patients admitted to the HCP/CHG between January 2011 and December 2012.

Data were collected in the HCP/CHG database and in the electronic records of patients through a standardized form of data collection that was developed by the researchers. This form included socio-demographic data and features that were related to the HCP/CHG service.

Among the socio-demographic characteristics, data related to age, sex and the primary care unit of reference of the patients was collected. The units of reference were grouped into three categories, depending on the treatment they were receiving and their mode of operation: Basic Units, Units of the Family Health Strategy of the Municipal Secretariat of Health, and Health Units administered by CHG.

The data with regard to the HCP/CHG service that were collected were duration of home care (days of monitoring by the program); number of home visits; outcome (rehospitalization, death or discharge by the referral healthcare unit) and a medical diagnosis provided by the primary or secondary International Classification of Diseases 10 (ICD 10). The most frequent infections were analyzed separately. Where the main ICD was referring to the use of some support technology or need for procedure, we used the secondary ICD and the information available in the electronic record.

Whereas the inclusion of patients in the HCP/CHG is done subsequent to consulting with Medical Services, the origins of patients regarding Hospitalization Units and their care teams was also analyzed.

As for nursing care, we collected information available in the database. This information dealt with the use of intravenous, subcutaneous and/or intramuscular medication; gastrostomy, jejunostomy or nasoenteric probe; need for in situ urinary catheter; management of colostomy, urostomy and/or tracheostomy; need for airway aspiration and management of wounds/ulcers during the follow-up period.

The study was approved by the Ethics and Research Committee of Conceição Hospital Group under number 202,473/2013. An Instrument of Consent was not required since it was research carried out on a database and electronic medical records. Throughout the study, the confidentiality and anonymity of the data was ensured, respecting the conditions of Resolution 466/2012⁽⁷⁾.

Data were stored in an Excel spreadsheet and analyzed by a statistician by means of the software SPSS 18.0. Descriptive statistics for the analysis and presentation of data were used. The normality of variables was analyzed by means of the Kolgomorov-Smirnov test. For the parametric quantitative variables, the mean and standard deviations were calculated; for the quantitative non-parametric variables, the median and interquartile range (P25-P75) was also calculated; for the categorical variables, absolute and relative frequencies (percentage and number of patients with the characteristics analyzed) were calculated.

Sociodemographic Profile
Eight hundred and twenty-six adults were supported by HCP/CHG in 2011 (n=438, 53%) and 2012 (n=388, 47%), among whom 445 (53.9%) were female. All were included in the study. The average age of the patients was 62.66±18.31 years, in which case the most prevalent age group was above 65 years (n=418, 50.6%), followed by the age group 51 to 64 years (n=230, 27.8%).

Regarding the referral health units (Table 1), 381 patients (46.12%) belonged to the catchment area of the Basic Health Units (BHU) of the Municipal Secretariat of Health, while 118 (27.60%) belonged to the Health Units (HUCHG)administered by the Conceição Hospital Group.

Table 1- Distribution of patients admitted to the HCP in 2011 and 2012 according to the referral healthcare unit. Porto Alegre, 2013.
Reference health units	%	n
Community Health CHG	27,60%	228
BHU	46,12%	381
ESF	14,28%	118
Health Center	6,90%	57
Out of area	4,72%	39
Not registered	0,38%	3
Source: HCP/CHG database.

Characteristics related to the cause of hospitalization of participants and attendance on the program
Table 2 presents the distribution of specialists who have referred patients for HCP/CHG in the period selected for this study. It can be seen that the internal medicine (33%) and the emergency (22.6%) units have forwarded the greatest number of patients to the HCP/CHG.

Table 2- Distribution of specialties that have referred patients for HCP in the years 2011 and 2012. Porto Alegre, 2013.
Specialty	n	%
Specialty	n	%
Internal Medicine	277	33%
Emergency	187	23%
Neurology	95	11%
Vascular surgery	65	8%
Gynecology and obstetrics	48	6%
Outhers	154	19%
Source: HCP/CHG database.

The main reasons for monitoring in the HCP/CHG Program, considering the diagnoses presented in the discharge report of the Program, were embolism and thrombosis (10.9%), cerebrovascular accident (stroke - 10.3%), pneumonia (8.4%), neoplasm (7.5%) and diabetes mellitus (DM - 7.3%), as detailed in Table 3.

Table 3 - Distribution of main ICDs of hospitalizations in the years 2011 and 2012. Porto Alegre, 2013.
	n	%
Main CID	n	%
Embolism and thrombosis	90	11
Encephalic vascular accident	85	11
Pneumonia	69	8,7
Neoplasia	62	7,5
Diabetes mellitus	60	7,3
Cardiac disorders	52	6,3
Urinary tract infection	49	5,9
Chronic Obstructive Pulmonary Disease	40	4,8
Skin Infections	33	4
Outhers	286	34
Source: HCP/CHG database.

The median follow-up period of patients in the HCP/CHG was equal to 21.5 days (13-36) and the number of visits made by the home hospitalization team averaged 5.0 (3.0 to 8.0).

As for the outcome of monitoring in the HCP/CHG, 629 patients (76%) were discharged from the Program and were referred to their health units of reference, 17 (2.05%) were administratively discharged, 22 (2.7%) died and 156 (18.9%) required rehospitalization. Among the deaths, 40% (n=9) had underlying pathologies such as neoplasm and pneumonia, and were predominantly over 65 years of age (n=18, 82%). Among those who required hospital re-admission (n=156), the main underlying pathologies were neoplasia (n=22, 14%), pneumonia (n=21, 13%) and stroke (n=19, 12%).

As to the age of this group of patients, most were older than 50 years (n=142, 91%), and 57% (n=89) were over 65 years.

Characteristics related to nursing care
During the study period, the main nursing demands of patients admitted to the HCP/CHG were the need to dressing (n=268, 32.4%), monitoring of blood glucose levels (n=163, 19.7%) and laboratory control for anticoagulation (n=125, 15.1%). 14.9% of patients (n=123) required handling of nasoenteric probes, while 8.7% (n=72) required the administration of intravenous medication, as detailed in Table 4.

Table 4 – Distribution of nursing care in the years 2011 and 2012. Porto Alegre, 2013.
Characteristics	n	%
Characteristics	n	%
Wound Dressing	268	32
Capillary glycemic control	163	20
Anticoagulation control	125	15
Nasoenteric sonda	123	15
Endovenous medicament	72	8,7
Subcutaneous medicament	55	6,7
Indwelling urinary catheter	48	5,8
Airway aspiration	43	5,2
Use of oxygen	25	3
Gastrostomy	21	2,5
Intramuscular medicament	13	1,6
Colostomy	7	0,8
Jejunostomy	3	0,4
Urostomy (yes)	3	0,4
Source: HCP/CHG database.

The data regarding age and gender observed in this study - predominantly of women and the elderly - are similar to another study found in the literature about the use of HC services in Brazil⁽⁸⁾. The study conducted in the HC service in the city of Montes Claros (MG) revealed a higher prevalence of women (54.7%) and patients aged between 61 and 80 years (37.2%)⁽⁸⁾.

The predominance of women among patients of HC services observed in studies conducted in Brazil, is also described in six rural towns in Japan⁽⁹⁾. The high prevalence among elderly patients of HCP/CHG is similar to that found in national and international relevant literature^(8,9). This is possibly explained by the aging population, the increased occurrence of chronic diseases and, consequently, greater demand for hospital care and use of other health services in this age group. "

The HC performed as part of the HCP/CHG promotes an interface between tertiary (hospital) and primary care, as upon discharge from the Program, patients are referred to their primary healthcare units. Given the difficulty associated with patients’ access to primary care, the HCP/CHG acts to accomplish this transition between hospital and the healthcare unit through communication established between services during or at the end of monitoring, ensuring the continuity of care. Almost half of the individuals who participated in the study were covered by the Basic Health Units of the Municipal Secretariat of Health, while about a third used the healthcare units associated with the CHG. It is noteworthy, in this context, that home care acts as an articulation mechanism between hospital services and the basic health units⁽¹⁾ in order to provide an opportunity for comprehensive care, since the scarcity of communication between these aspects of health care favors the segmentation of care, and reduces its ability to meet the specific needs of the user⁽¹⁰⁾.

The emergency rooms and inpatient units in the Internal Medicine departments of four CHG hospitals were those that most requested consulting on the part of the HCP/CHG. The fact that patients are referred by general care units points to a great diversity among the clinical patients of the Program. Indeed, the underlying pathologies of the hospitalized patients with regard to the HCP/CHG during the study period were quite varied. The analysis of the HC service in Montes Claros (MG) as previously cited, also identified a diversity of diagnoses - twelve kinds of underlying diseases were described, totaling 41% of the pathologies presented by the patients who were evaluated. Pneumonia and diabetes mellitus were the most prevalent⁽⁸⁾.

Among the diagnostic causes for hospitalization in HCP/CHG, embolism and thrombosis were the main issues. This finding is explained by the fact that the HCP/CHG is a reference unit within the Conceição Hospital Group for oral anticoagulation of thromboembolic phenomena prophylaxis and treatment. In addition, thromboembolic events such as deep vein thrombosis, pulmonary embolism and stroke are more prevalent in the elderly⁽¹¹⁾, the predominant age group in the sample that composed the study. Moreover, the presence of strokes as a second most common cause for diagnostic monitoring in HCP/CHG is consistent with the global reality, since cardiovascular diseases affect about 17 million people worldwide⁽¹²⁾. Neoplasms and diabetes mellitus were also frequent reasons for hospitalization, which corroborates the epidemiological profile of these clinical conditions in the population. Data for the Surveillance of Risk and Protective Factors for Chronic Diseases by means of Telephone Inquiry (VIGITEL) of 2011 suggest a prevalence of diabetes mellitus in 5.6% of the population, in which case it is higher in the elderly, women, and individuals with less education, - common features of the patients of HCP/CHG⁽¹³⁾. In relation to neoplasms, according to the global report of non-communicable diseases of the World Health Organization (WHO), cancer will become a major cause of morbidity and mortality in all regions of the world in a few decades⁽¹²⁾. Estimates of the same report demonstrate the increased incidence of cancer - 12.7 million new cases in 2008 to 21.4 million in 2030. This fact was related to different causes, including increased life expectancy and population aging⁽¹²⁾.

The average length of hospitalization of patients in the HCP/CHG was 21.5 days, and the number of visits made by the home care team was 5.0. Most patients were discharged from the Program and were redirected to their Healthcare Unit. Approximately 3% of patients died, and 19% required rehospitalization. The main causes of death and rehospitalization are consistent with the WHO data, which indicate cardiovascular diseases, neoplasms, chronic respiratory diseases and diabetes as the main causes of global mortality due to non-communicable diseases⁽¹²⁾; and pneumonia as one of the central causes of hospitalization in the health system, among the infectious diseases.

The demands on nursing within HC are numerous. In the present study, the main ones were dressing wounds and the monitoring of blood glucose. The predominance of elderly patients and pathologies associated with greater physical dependence among the patients of the sample, can justify the need for specific nursing care. The assistance provided by the nursing staff, regardless of demand, contributes to a better patient care and to a solution for patients’ problems. A systematic review has shown positive results in terms of the home care performed by nurses in relation to the recurrence of leg injuries, caregiver stress and global health issues⁽¹⁴⁾. Another piece of research has also shown positive results on terms of reducing mortality in the elderly population, in general, through home visits (RR: 0.76, CI 0.61 to 0.89)⁽¹⁴⁾. Therefore, we highlight the key role of nurses who are prepared to deliver home care, which allows the provision of care consistent with social reality through guidance to patients, carers and family, without disregarding the uniqueness of the elements involved in home care, but with mutual and simultaneous support⁽¹⁵⁾.

Different nursing actions were provided for patients of the HCP/CHG during the study period. Therefore, the implementation of the home care plan points to a potential benefit to the patient, since nurses guide and adapt their methods to the home, in order to empower patients and caregivers in terms of effective care, adapting existing resources to the needs of the individual. It is also noteworthy that often different nursing demands are common to the same patient. This leads to a greater complexity of care, and its determination (within the profile and in terms of the patient’s social status) of the basis for nursing care, and to the need for guidelines and training for patients and carers.

The classification of care complexity allows the prioritization of attention with regard to cases that require greater resources in terms of health services and with regard to the monitoring of the multidisciplinary team. It is one of the determining factors mentioned in the Notebook Home Care of the Health Ministry for eligibility of the individual concerning HC services⁽¹⁾. The HC modalities established by it contemplate the home care performed by the primary care team in terms of medically stable patients with a reduced need for health resources, and who are unable to go to the Health Unit (referred to as HC1); the care provided by HC multidisciplinary teams and multidisciplinary support teams, in terms of specific services of HC to patients presenting health problems requiring continuous monitoring (modality HC 2); and patients who require more complex care, such as oxygen therapy, ventilatory support, paracentesis and peritoneal dialysis (modality HC 3)⁽¹⁾.

The present study provided us with an opportunity to characterize a representative sample of patients of HCP/CHG, which will contribute to a better management of care by the staff, particularly that provided by nursing staff. The fact that the study was done by means of the collection of data in electronic databases and medical records can be a potential limitation, as such a methodology impedes standardization terms of data collection. Likewise, it was only possible to identify nursing interventions related to supporting technologies, need for dressing, and laboratory examinations.

The assistance provided by the nursing staff, regardless of demand, can improve the care provided to patients through continuity of care, and also helps to prevent readmissions. Longitudinal studies may help the confirmation of these inferences.

At the end of the follow up period conducted by the HCP/CHG, most patients were referred to their health unit, reinforcing the role of the Program in promoting an interface between primary and tertiary care. This act is important in terms of strengthening the relationship of the user with the network of primary health care.

The characterization of patients contributes to the literature on the subject, allowing greater insight into the profile of patients of HC public services, and may provide better qualified services.

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