Dehospitalization of Elderly People in Situations of Social Vulnerability: The Experience of Belo Horizonte

Abstract

This report describes the innovative experience of the Municipal Health Department of Belo Horizonte in the discharge of socially vulnerable elderly patients. Through the work of a nurse acting as a technical reference in hospitals of the SUS-BH network, intersectoral actions between health and social care were coordinated to enable safe discharge for patients without family support. The case of an elderly man hospitalized for two years after clinical discharge is presented, highlighting a methodology based on comprehensive assessment and an action plan that included dialysis transportation and admission to a Long-Term Care Institution (LTCI). The experience showed that, although complex, hospital discharge is feasible when care networks are effectively integrated. The initiative contributes to improving care quality, freeing up hospital beds, and ensuring the right to a dignified life, challenging the paradigm of social isolation often imposed on vulnerable elderly individuals.