Hospital management and transitional care of chronic disease


Knowledge on an innovative hospital structure, dedicated to the proactive management of chronic diseases and decompensations in the hospital setting, and transitional care between hospital and primary health care. Experience the activity of a multidisciplinary team with care practice, teaching and research in full operation at Hospital São Francisco Xavier/Centro Hospitalar de Lisboa Ocidental  Day Hospital.

-        Learn the concept of “Transitional Care” between the hospital and outpatient setting.

-        Practice effective communication methodology, mainly with Primary Care health practitioners

-        Practice communication with patients, family members/caregivers about disease progression, adherence to non-pharmacological measures, pharmacological therapy (adherence, effects, adverse effects, dose titration)

-        Teaching methodology about education on disease management and its monitoring

-        Experience and understand the role of each health professional in a multidisciplinary team.


General characterization





Responsible teacher

Profª Doutora Cândida Fonseca


Weekly - Available soon

Total - Available soon

Teaching language

Available soon





- International Diagnostic and Treatment Recommendations of Chronic Disease when available

- Action protocols of the MSDH

- Published texts by the faculty of OCU

- Bibliographical material obtained by internet search


Teaching method

In the MSDH, students will work in direct interaction with the multidisciplinary team, namely nursing team, with the supervision of a doctor.

Activity Notebook




Discussion of application of diagnostic protocol



Experienced therapeutic protocols




IV (intravenous)

SC (subcutaneous)

IM (intramuscular)



Discussion of complementary diagnostic exams: ionogram, blood count, GFR calculation, liver function evaluation, natriuretic peptides…



Thoracic radiograph report



EKG report



Non-invasive monitoring



Blood transfusion/Flebotomy



IV Iron administration



Oxygen Therapy



Correction of hidroelectrolitic disturbances



Correction of fluid overload and treatment monitoring



Indications/Introduction of oral anticoagulants (OAC)



Monitoring of OAC patients



Training in transitional care



Education of patient/caregiver about disease and self-control



Clinical Investigation contact



Evaluation method


-        Discussed report (Index 0,50) - (last day of the OCU)

-        Continuous tutor´s evaluation (Index 0,50)

Report (Layout)

The student should compose a summarized report of the activities that should include the following:

-        Tutor

-        Summarized description of the location, the multidisciplinary team and his/her role in daily activities

-        Registration of the executed activities and the witnessed activities

-        Summarized description and critical evaluation of the developed activity and structure: MSDH.


Subject matter

Experience and collaboration in care in outpatient setting, in the hospital, to chronic disease: Diabetes mellitus (DM), Heart Failure (HF), oral anticoagulation, anaemia of chronic diseases.

Education of patient and caregiver, on disease and self-control

Individualized therapeutic algorithm

Practice on Titration of drugs modifying disease (HF)

Treatment of acute complications, avoiding admission vs admission decision

Training in the management of IV drugs in day hospital avoiding admission

Timing for referral to a HF/DM consult vs primary care

Training on diagnosis of chronic disease anemia;

Familiarization with methodology of IV iron reposition and blood transfusion in outpatient setting

Indications of the anticoagulant drugs

Management of thromboembolic and hemorrhagic risk scores

Familiarization with the point-of-care methodology and computerized INR control program and coumarin dosage

Training interaction with primary health care

Contact with investigation teams: general methodology and duties of investigators, informed consent.



Programs where the course is taught: