Introduction

The Unified Health System considers that hospital care is important for the construction of integrality. Residents in a Multi-professional Residency Program to the Hospital Universitário da Universidade de São Paulo indicated, difficulties of the medical and nursing staff were identified to detecting demands for rehabilitation at hospital discharge, which encouraged residents to create a support group to hospital discharge.

Objective

To verify the sociodemographic and health profile of users accompanied by the support group, identify challenges for insertion of these users in the rehabilitation care network and identify strategies of the support group to face these challenges.

Method

Retrospective, exploratory and descriptive study, based on the documentary analysis.

Results

We analyzed forms of 251 users, 83 (33%) received a referral for rehabilitation at discharge and 17 (6.7%) received referral after guidelines of the discharge support group; 95 (37.8%) sought rehabilitation services. Of these, 60 were effectively included in the services, of which 46 (18.3%) were extra-hospital, such as rehabilitation centers, basic health units and 14 (5.6%) in the Hospital Home Care Program. Concerning professional areas, 34 (13.5%) started physical therapy treatment, 29 (11.6%), speech therapy and 11 (4.9%), therapeutic-occupational. It was identified insufficiency of professional referrals and difficulties of users regarding access and continuity of care. To cope with challenges, the support group has reinforced prescribed referrals or directed obtaining referrals in medical consultations on the network.

Conclusion

The group has tried to understand user demands by professional area, oriented users to access services and to get treatments. The users have valued the receptiveness of the support group, being a strategy to promote integral health care.

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