Abstract
OBJECTIVES: to propose an outpatient discharge management model from specialized care to primary care to promote continuity of care for chronic conditions. METHODS: action research with a qualitative approach. Twenty-eight professionals, including physicians, nurses, and public administrators, participated. Data collection was carried out through participant observation, documentary research, semi-structured interviews, and workshops. The data were subjected to Creswell's content analysis. RESULTS: eight categories and 22 subcategories supported the creation of the outpatient discharge management model, emphasizing communication among levels of the healthcare network, designating the nurse as the process coordinator, and encouraging collaborative practices. FINAL CONSIDERATIONS: the study proposed an outpatient discharge management model focused on continuity of care, in addition to reinforcing the role of nurses, highlighting attention to communication, technological support and collaborative practices, reaffirming the importance of Primary Health Care as a care organizer.