Abstract

Objectives: Fragmentation of continuity of care impacts the health system's efficiency and increases inequity. It severely affects high-risk patients with multimorbidity, requiring coordinated care to avoid preventable complications. The Centro de Fund, implemented a transitional care strategy for high-risk adults with multimorbidity at 3 hospitals in the southeast of Santiago. The study aimed to evaluate the impact on length of hospital stay, consultations with primary care physicians and contacts after discharge, and also to describe the implementation process of the transition nurse activities.Methods: A cohort study was performed between 2017 and 2019, with 137 hospitalizations from exposed patients and 167 hospitalizations from unexposed patients. The results of the study showed a significant decrease in the length of hospital stays and an increase in consultations with physicians.Results: The results of the implementation process showed that the transition nurse followed-up in a mean of 24 hospitalizations monthly, and 91% of the discharged patients were contacted via the telephone within 7 days. The implementation process showed that the transition nurse's tasks merged with the daily clinical activities in which training on case management, transition care, and continuous support were key aspects of success.Conclusion: We conclude that transitional care intervention has a strong potential in addressing fragmentation of care and is feasible to install and sustain over time in the Chilean context. Finally, this study provides a detailed description of the intervention strategy contributing to its spread and scale-up.