Transition of care to the home for individuals with Diabetes Mellitus: a concept analysis based on RodgersABSTRACT
Objective: To analyze the concept of transition from care to home for people with diabetes mellitus from Rodgers’ evolutionary perspective.
Method: This is a conceptual analysis based on Rodgers’ evolutionary model. Data collection was carried out in October 2024, through online access to data sources using the Decs/Mesh/EMTREE descriptors: “Cuidado transicional/Transitional care/Home transition”, “Diabetes Mellitus” and “Alta do paciente/Patient Discharge/Discharge Planning” connected by boolean operators AND e OR.
Results: After selection, 34 studies were included in the analysis. Essential characteristics of the transition of care to the home for people with diabetes and its significance were identified, contributing to a better understanding of the aspects that identify this care, the conditions for its occurrence, and its results.
Conclusion: The concept contributes to better identification of challenges for its implementation in clinical practice and post-discharge follow-up, aiming to improve coordination between levels of health care and safe longitudinal care.
KEYWORDS:
Transitional Care; Diabetes Mellitus; Patient Discharge; Hospital to Home Transition; Models, Theoretical
HIGHLIGHTS
Improved coordination between levels of healthcare.
Longitudinal care to meet the needs of people with diabetes.
Promotion of effective and safe care transition strategies.
RESUMO
Objetivo: analisar o conceito de transição do cuidado para o domicílio da pessoa com diabetes mellitus na perspectiva evolucionária de Rodgers.
Método: trata-se de uma análise conceitual baseada no modelo evolucionário de Rodgers. A coleta de dados foi realizada em outubro de 2024, por meio de acesso online às fontes de dados usando os descritores do Decs/Mesh/EMTREE: “Cuidado transicional/Transitional care/Home transition”, “Diabetes Mellitus” e “Alta do paciente/Patient Discharge/Discharge Planning” conectados pelos operadores boleanos AND e OR.
Resultados: após a seleção, resultaram 34 estudos para análise. Foram identificadas características essenciais da transição do cuidado para domicílio da pessoa com diabetes e seu significado, contribuindo para o melhor entendimento dos aspectos que identificam esse cuidado, as condições para sua ocorrência e seus resultados.
Conclusão: o conceito contribui para a melhor identificação dos desafios para sua implementação na prática clínica e acompanhamento pós-alta, visando melhoria da articulação dos níveis de atenção à saúde e um cuidado longitudinal seguro.
DESCRITORES:
Cuidado Transicional; Diabetes Mellitus; Alta do Paciente; Transição do Hospital para o Domicílio; Modelos Teóricos
HIGHLIGHTS
Melhoria da articulação entre os níveis de atenção à saúde.
Cuidado longitudinal para atender às necessidades das pessoas com diabetes.
Promoção de estratégias de transição de cuidado eficazes e seguras.
RESUMEN
Objetivo: analizar el concepto de transición de la atención domiciliaria de las personas con diabetes mellitus desde la perspectiva evolutiva de Rodgers.
Método: se trata de un análisis conceptual basado en el modelo evolutivo de Rodgers. La recopilación de datos se llevó a cabo en octubre de 2024, mediante el acceso en línea a las fuentes de datos utilizando los descriptores Decs/Mesh/EMTREE: “Cuidado transicional/Transitional care/Home transition”, “Diabetes Mellitus” e “Alta do paciente/Patient Discharge/Discharge Planning”, conectados por los operadores booleanos AND y OR.
Resultados: tras la selección, se seleccionaron 34 estudios para su análisis. Se identificaron características esenciales de la transición de la atención domiciliaria de las personas con diabetes y su significado, lo que contribuye a una mejor comprensión de los aspectos que identifican esta atención, las condiciones para su ocurrencia y sus resultados.
Conclusión: el concepto contribuye a identificar mejor los retos para su implementación en la práctica clínica y el seguimiento tras el alta, con el fin de mejorar la coordinación entre los distintos niveles de atención sanitaria y garantizar una atención longitudinal segura.
DESCRIPTORES:
Cuidado de Transición; Diabetes Mellitus; Alta Hospitalaria; Transición del Hospital al Domicilio; Modelos Teóricos
HIGHLIGHTS
Mejora de la articulación entre los niveles de atención sanitaria.
Cuidado longitudinal para satisfacer las necesidades de las personas con diabetes.
Promoción de estrategias eficaces y seguras para la transición asistencial.
INTRODUCTION
Diabetes mellitus (DM) and its complications are the leading cause of premature death in several countries, accounting for 3.4 million deaths in people aged 20 to 79 in 2024. It is an important global challenge because it affects the health of individuals, families, society, and health systems through its impact on people’s quality of life, disabilities, loss of productivity, and chronic complications arising from the disease1-2.
Sometimes, hospitalization of these patients is necessary, mainly due to a worsening of their health condition, with severity that requires therapeutic or diagnostic intervention or careful monitoring. Intrinsic to this, hospital discharge is a complex process, fraught with challenges3-4.
To this end, discharge management is an essential tool that requires planning and systematization to promote more effective and targeted interventions, with a view to integration with other points of care, as well as considering the patient’s return home3.
Because it is a chronic condition, people with DM require ongoing care from various points in the healthcare network (HN) to ensure that the transition of care occurs effectively. Care Transition is the foundation for continuity of care and one of the main strategies for linking NHs. The transition of care process can occur between different sectors of the same institution, such as from a hospital to an outpatient clinic, primary care, or even to the patient’s home5.
The transition from hospital to home care and continuity of care in health services are vulnerable processes, especially for people living with chronic diseases, multiple comorbidities, complicated treatment regimens, or limited caregiver support6. A study conducted with people with DM found that the lack of planning and involvement of patients or their families in education and self-management of their disease and medications is associated with increased rates of hospital readmissions7.
On the other hand, Care Transition strategies reduce readmissions for preventable causes, pointing out that the better the preparation for self-management, the lower the readmission rates within 30 days. In addition, there is a positive impact by improving the quality of life of patients and their families, as well as minimizing the occurrence of Adverse Events (AE), strengthening Patient Safety8. Accordingly, people with DM, due to their complex therapeutic regimen, generally receive care at various points in the NH and frequently move around in care settings. Therefore, they are more vulnerable to discontinuity of care9.
According to a conceptual analysis of transitional care, the proper implementation of the Transition of Care should consider several factors, such as the situation of patients and families, the participation of different members of the healthcare team, and environmental and social conditions and facilities. This study examined transitional care for different populations, such as the elderly, people affected by myocardial infarction, stroke, and mental disorders10.
Some concepts related to the Transition of Care were found in the context of patients with heart failure11 and people withcancer12. Thus, there is a shortage of production related to diabetes. Therefore, a thorough analysis of the transition of care to the home of people with DM is necessary. This understanding may contribute to improving the hospital discharge process and quality of care, with a consequent reduction in readmission rates and healthcare costs. Furthermore, it is hoped that theoretical discussions will become more consistent.
That said, considering that concepts evolve over time, it is pertinent to conduct a conceptual analysis of the transition of care to the home of people with DM based on Rodgers’ evolutionary method13, which is characterized by clarifying vague and ambiguous understandings, taking contextual aspects into account. Understanding the concept, considering its historical and contextual use, allows us to grasp the essence of the concept, contributing to a more effective use of the term.
In view of the above, the following guiding question is presented: “What is the definition of the concept of Transition of Care to the home of people with Diabetes Mellitus according to scientific health publications?” The study aimed to analyze the concept of Transition of Care to the home of people with Diabetes Mellitus, from Rodgers’ evolutionary perspective.
METHOD
This is a conceptual analysis based on Rodgers’ evolutionary method, which describes six stages for achieving the proposed objective: I) define the concept of interest; II) select the field for data collection; III) highlight the attributes of the concept and contextual bases (antecedents and consequents); IV) analyze the characteristics of the concept (substitute terms and related concepts); V) identify, if necessary, an example of the concept; and VI) determine the implications of the concept13.
The antecedents are events/phenomena that contributed to the emergence of the term, while the consequents refer to the consequences after the term was applied. Substitute terms are words or expressions that replace the term, and related concepts refer to assumptions that formulate the meaning of the term analyzed13.
In this study, the concept of interest was defined as “Transition of Care to the Home of People with Diabetes Mellitus” in order to promote robust and more complex discussions on the topic and clarify the applicability of the concept in the approach.
Data collection was carried out in October 2024 in the following databases, repositories, and directories: American Literature in Health Sciences (LILACS), Medical Literature Analysis and Retrieval System Online (MEDLINE) via Pubmed, BDENF, SCOPUS, Web of Science, COCHRANE, SciELO, EMBASE, in addition to the CAPES Thesis and Dissertation Portal and the Brazilian Thesis and Dissertation Database (BBTD), for allowing more in-depth reflections on the topic.
Data related to the identification of the material were extracted, such as: authorship, year of publication, country of study, type of publication, objective, method, area of knowledge, population; and data related to the concept: attributes, antecedents, consequents, substitute terms, and related concepts.
In the search fields, a combination of controlled descriptors was used, according to DeCS/MeSH/EMTREE: “Cuidado transicional/Transitional care/Home transition”, “Diabetes Mellitus” and “Alta do paciente/Patient Discharge/Discharge Planning”, connected by the Boolean operators AND and OR, using search strategies according to each data source, as shown in Chart 1.
As this is an evolutionary analysis of the concept, no time frame was established. Full publications available electronically in Portuguese, English, or Spanish on the subject were included. Excluded were editorial productions, summaries, experience reports, letters to the editor, ongoing studies, and those that did not correspond to the concept of interest.
The selection of studies followed three stages: identification of studies; evaluation of titles and abstracts; and full reading of the preselected studies, in pairs. The study did not involve research with human beings and therefore did not require ethical review.
Two reviewers independently assessed the eligibility of the studies using Rayyan QCRI online software14 and Excel spreadsheets to manage the studies. Initially, reviewers conducted a screening based on the titles and abstracts. Subsequently, each of the selected studies was read in its entirety to confirm its permanence and, if so, extract the data of interest, justifying the exclusion of the others according to the established criteria. Next, the references were analyzed for inclusion of new studies.
The data collection indicators were guided by the definitions and questions of Rodgers’ evolutionary method and are summarized in Chart 2.
A thorough review of all selected material was conducted to analyze the information and assess the knowledge. The authors followed the recommendations of the Preferred Reporting Items for Systematic Reviews and Metas - Extension for Scoping Reviews (PRISMA-ScR), as outlined in the JBI Manual15. The findings were presented using thematic categories based on similarity of content.
RESULTS
The initial search resulted in 5,693 articles, and after filtering, 2,949 were selected for export to the selection software by independent reviewers. After screening using the inclusion and exclusion criteria, the final sample consisted of 34 publications (Figure 1).
Flowchart of the search and selection of studies based on Prisma-ScR. Fortaleza, CE, Brazil, 2024
All 34 materials analyzed were articles. The year with the most publications was 2024 (5-14.7%), followed by 2023, 2022, and 2021 with four (11.7%) in each year. The country that stood out in terms of production was the United States of America (USA) (18-52.9%), followed by China (5-14.7%).
In terms of knowledge areas, nursing stood out (32-94.1%), followed by medicine and public health, with one publication (2.9%) each. As for the study population, patients were more frequent (28-82.35%), followed by professionals (6-17.6%).
The relevant data extracted were presented separately as attributes, antecedents, and consequents. The attributes were categorized into three main classes: ‘patient-related attributes’, ‘nurse-related attributes’, and ‘organization-related attributes’. The background information included two main categories: “patient-related background” and “care process-related background.” The consequences were categorized into two main classes: “patient-related consequences” and “care process-related consequences” (Figure 2).
With regard to the description of conceptual aspects according to each categorization, the main attributes, antecedents, and consequences of the concept of transition of care for people with diabetes at hospital discharge, as identified by the studies investigated, are presented in Chart 3.
Background, attributes, and consequences of the conceptual analysis of the transition of care to the home of people with diabetes. Fortaleza, CE, Brazil, 2024
The replacement terms included: transitional care in diabetes, transitional care in the hospital discharge process, and transitional nursing care. The related concepts identified were continuity of care, coordination of care, discharge planning, liaison nurse, follow-up plan, and survival care plan.
Based on the conceptual analysis, Transition of Care to the Home for People with Diabetes Mellitus is defined as a complex, multidisciplinary, and individualized strategy during the hospital discharge process for people with diabetes mellitus that requires planning and effective communication to improve self-management, treatment engagement, clinical outcomes, and caregivers’ ability to provide care. in addition to optimizing coordination between hospital resources, other levels of health care, and social support systems in order to ensure post-discharge follow-up and continuous, safe, and quality care for people with diabetes.
DISCUSSION
The data analysis showed that no Brazilian studies were found, with most publications developed in the US, confirming the scarcity of research in Brazil related to the transition of care for people with diabetes, especially in the context of hospital discharge16.
There has been an increase in the number of publications over the years, with a notable increase in 2024. This demonstrates greater interest in more effective and safer transition-of-care methods for people with DM. In addition to the use of tools that support this process, such as soft, hard, and hard technologies, to promote longitudinal care, ensure patient safety, and prevent harm resulting from poorly structured/executed transitions17-18.
The prominence of the field of nursing can be attributed to the fact that nurses are more involved in care transition processes. In addition, they demonstrate greater skill and ability in developing transition strategies/tools during patient care19-20. Furthermore, nursing care stands out for its proximity to patients in the pursuit of effective care, considering patients and family members as key players in safe care19,21.
Several studies18,22-24 have shown that nurses have developed and/or tested strategies for the transition of care for people with diabetes, reinforcing the importance of tools for a safe and high-quality transition for this population. When poorly executed, the transition of care can cause serious harm to patients and health services. Therefore, the implementation of techniques and the development of valid instruments that support this process are essential, assisting in the care provided.
Most of the studies analyzed predominantly included patients as core participants. This is because this population is entitled to the essential care that permeates this transition process, which has an impact on their monitoring, treatment, and, consequently, their quality of life. This finding is supported by studies25-26 that emphasize that the patient and their family member/caregiver are the most affected in this stage, regardless of the outcome, since in cases of inadequate transitions, they may be more susceptible to discontinuity of care, inadequate follow-up or its absence, uncertainties, and insecurity regarding treatment management. On the other hand, well-designed and coordinated Care Transition actions provide continuous patient monitoring, greater safety in disease care, encouragement of self-care, better adherence to treatment, and, consequently, lower risks of complications.
Regarding the aspects of concept analysis, according to Rodgers’ evolutionary model,13 the patient’s demands in this vulnerable process stand out, since this profile of individuals requires more targeted and individualized guidance, especially regarding drug therapy, such as the use of oral antidiabetic drugs (ADDs) and/or insulin. Researchers19,27 emphasize the need for closer attention to people with DM, since the disease is a complex condition. Glycemic control is constantly sought, and diabetes education is a fundamental pillar because it promotes self-care and greater involvement of the person and/or family member/caregiver in their treatment.
Furthermore, communication between professionals and patients/caregivers and among healthcare team members themselves, in addition to an interdisciplinary approach, were highlighted as antecedents that directly influenced the outcomes of the Transition of Care and were considered essential aspects of this process. These findings are consistent with the literature,28-29 which points out that communication skills have the potential to establish links and build bridges between services, ensuring better care and coordination among health professionals. The interdisciplinary team’s work is essential, as each professional has their own particular skills and contributes to providing comprehensive care for patients with DM.
As for the consequences, terms such as “longitudinal care,” “post-discharge follow-up,” and “safe care” emerged, demonstrating aspects intrinsic to this process, as well as the associated benefits, by ensuring that patients receive support during the hospital discharge process in a safe manner. Research25,30 confirms that the adoption of transitional care promotes more qualified assistance, as it provides continuity of care and follow-up of patients at other levels of care and/or at home, through managerial, educational, and communication processes.
Continuity of patient care after hospital discharge is essential to prevent patients from falling through the cracks in the healthcare system and receiving fragmented care due to a lack of knowledge about the services available to them when needed. The weaknesses of the counter-referral mechanisms lead to helplessness and insecurity among patients/family members, often resulting in the search for inadequate services, such as Emergency Care Units (UPAs), which are intended for urgent and emergency care21,31.
In this perspective, Transition of Care actions influence care practices, encouraging frequent preventive activities, better integration with health services, harm reduction, and, consequently, control of risk factors related to care32. As a result of the transition in care for people with DM, improvements have been seen in therapeutic outcomes, patients’ quality of life, and reduced costs to the healthcare system. Other consequences found include: better glycemic control, with reduced levels of Glycosylated Hemoglobin (HbA1c), reduction of acute complications (hypoglycemia, hyperglycemia, Diabetic Ketoacidosis/DKA), as well as greater patient engagement and adherence to treatment18,30,33.
Regarding the attributes of the concept studied, Care Transition is associated with patient involvement in the transition process, the importance of the nurse’s role, the implementation of individualized care plans, diabetes education practices, as well as case management, an interdisciplinary approach, communication, and coordination of care. These aspects are highlighted in studies18,33-34 that point to the need for an individualized approach to patients in order to meet their demands and implement systematic and organized transition measures to optimize the care provided. To this end, care transition measures for patients with DM must be implemented with quality and safety, in a standardized manner, through the development of management tools supported by scientific evidence.
In addition, communication and coordination of care were strongly identified as other characteristics of transitional care in patients with DM. This care is complex and must be personalized and multidisciplinary, involving various healthcare providers, such as doctors, nurses, pharmacists, physical therapists, and nutritionists. Communication and coordination between hospital resources, other levels of health care, and the social support system are essential for managing transitional care. Common goals, responsibilities, and shared values drive team-based transitional care for people with DM28.
The transition of patients with complex conditions from hospital to primary and/or secondary care services, as well as to their homes, depends on effective communication and requires greater attention to the entire context involved in the care and discharge of each individual31. Thus, among other aspects, it is understood that there is a complex dynamic involved in the context of hospital discharge of people with chronic diseases, especially DM, and the responsibility assigned to professionals, services, as well as the entire Health System6.
As for the limitations of the study, it should be noted that all materials retrieved were related to research articles published in journals, and no gray literature was included. This could potentially undermine a richer understanding of the dimensions of this concept. Furthermore, the decision to only consider works in English, Portuguese, and Spanish may have limited the selection of publications. On the other hand, most of the included studies used qualitative research designs or were systematic reviews, which enriched our findings.
CONCLUSION
The concept presented contributes to better identification of the challenges for its implementation in clinical practice and post-discharge follow-up, aiming to collaborate in improving the coordination of health care levels and safe longitudinal care in order to meet the needs of people with DM and avoid hospital readmissions and adverse events.
The study identified the essential characteristics of the transition to home care for people with diabetes mellitus, clarifying its meaning and broadening understanding of the elements that define this care, the conditions that enable it, and the results associated with it. This conceptual analysis presents evidence-based information and quality improvement strategies to ensure that transition processes produce the desired results.
Thus, we seek to contribute to the explanation of the concept evaluated, with the aim of establishing a relationship between the concept of “Transition of Care” and “Diabetes Mellitus,” based on scientific literature, to clarify this process and the aspects that permeate it. With this, it is hoped that this study will serve as a basis for future research, such as studies evaluating transitional care and the development of tools to facilitate this process.
ACKNOWLEDGEMENTS
This work was carried out with support from the Coordenação de Aperfeiçoamento de Pessoal de Nível Superior (CAPES) - Funding Code 001.
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Data availability:
The authors declare that all data are fully available within the article.
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HOW TO REFERENCE THIS ARTICLE:
Freire VAL, Correia DL, de Oliveira SKP. Transition of care to the home for individuals with Diabetes Mellitus: a concept analysis based on Rodgers. Cogitare Enferm [Internet]. 2025 [cited “insert year, month and day”];30:e97890en. Available from: https://doi.org/10.1590/ce.v30i0.97890en
The authors declare that all data are fully available within the article.
Source: The authors (2024).
Source: The authors (2024).