The Lezíria Local Health Unit (ULS Lezíria) participated in the World Nursing Science Conference (WNSC 2026), held from September 18 to 20, in Miami, USA. Dina Isabel Coito Bernardino, a nurse specialist in community nursing, presented a model for patient follow-up after hospital discharge by primary healthcare nurses.
The communication, titled “Post-Hospital Discharge Follow-Up by Nurses in Primary Health Care as a Model for Integration and Safe Transition of Care”, highlighted the importance of early nursing intervention in the post-discharge period to reinforce continuity and integration of care. The model focuses on initial nursing assessment, identification of needs, referral to appropriate resources, and improving information flow between hospital and primary care.
The presentation emphasized the first three days after discharge as a critical period, where difficulties may arise with medication management, recognizing warning signs, self-care, nutrition, caregiver support, and access to health and community resources.
Participation in the international meeting allowed for the sharing of knowledge and practices from ULS Lezíria, promoting reflection on the role of nursing, particularly primary healthcare nurses, in ensuring safer, integrated care transitions centered on the needs of individuals and families.
