Introduction:

Active aging is a European concern that requires health and social professionals to rethink their practices.

Methodology:

We seek to understand the care model for the elderly in a Group of Health Centers (ACES) in the North of Portugal to deduce the role of rehabilitation nurses in the community. We carried out a qualitative, phenomenological study. The intentional non-probabilistic sample consisted of eight Doctors, eight Nurses and eight Social Workers who develop their activity for people over 65 years old in an ACES. Data collection was carried out through a semi-structured interview, constituting the results of the body of analysis that sustains this research.

Results:

83% of participants had no training in gerontology. There were care evaluation focuses, in which all professionals estimated the same data, but there were data necessary for monitoring the elderly that were not evaluated by any professional. The sharing of information for assistance, when it occurred, fell into situations of illness or changes in the social context.

Discussion:

It was possible to verify that in all themes there is information that converges in the three groups of professionals, mainly in the data collected in the initial evaluation. As advocated by some authors, sharing information and dividing teamwork is important for a more specialized intervention aimed mainly at this age group.

Conclusion:

In this way, it was possible to perceive that the work of the three groups of professionals interviewed often intersects and that there is a need for data sharing between the multidisciplinary team, with the specialized work of the Rehabilitation Nurse being valued and important.

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