Post-discharge follow-up model

This document presents a graduate project aimed at designing a post-discharge follow-up model for patients treated in the emergency department, in order to strengthen continuity of care and reduce avoidable readmissions. The main problem is the discharge without a standardized follow-up plan, associated with communication failures, absence of protocols, low articulation between levels (emergency - outpatient - primary care) and technological limitations, with impact on patient safety, institutional efficiency and user satisfaction. Based on documentary review and evidence, strategies such as early telephone follow-up (48-72 hours), tele-guidance/telemedicine, patient education (teach-back, clear instructions) and coordination with insurers and care networks stand out. The analysis highlights the gap between the current discharge pathway focused on delivering instructions and an ideal pathway that records discharge, activates follow-up, identifies warning signs, facilitates referral and measures user experience. A pilot is recommended with indicators of adherence, readmission and quality, and pre-post evaluation to estimate effectiveness.