Primary care for diabetes mellitus patients from the perspective of the care model for chronic conditions

ABSTRACT Objective: to assess the health care Primary Health Care professionals provide to diabetes mellitus patients from the perspective of the Modelo de Atenção às Condições Crônicas. Method: qualitative study, using the theoretical framework of Complex Thinking and the Modelo de Atenção às Condições Crônicas and the methodological framework of assessment research. To collect the data, 38 interviews were held with health professionals and managers; observation of the activities by the health teams; and analysis of 25 files of people who received this care. The data analysis was supported by the software ATLAS.ti, using the directed content analysis technique. Results: at the micro level, care was distant from the integrality of the actions needed to assist people with chronic conditions and was centered on the biomedical model. At the meso level, there was disarticulation among the professionals of the Family Health Strategy, between them and the users, family and community. At the macro level, there was a lack of guiding strategies to implement public policies for diabetes in care practice. Conclusion: the implementation of the Modelo de Atenção às Condições Crônicas represents a great challenge, mainly needing professionals and managers who are prepared to work with chronic conditions are who are open to break with the traditional model.

To analyze the data, the combination of the adopted techniques permitted triangulation in the analysis process, which was guided by directed content analysis.
The MACC served as a reference, in view of its range (micro, meso and macro) (7) , and the protocol proposed in the Health Department policy for diabetes: Primary Care Notebooks -Strategies for care to chronic patients -Diabetes Mellitus (9) .
ATLAS.ti software version 7.1.7 was used, license 58118222, as a technological tool to support the organization and coding of the interview. The analysis of these data involved coding, the initial analysis when the data were opened and the codes originated in the interviews were identified; and the reorganization of the data around axes of interest, guided by the theoretical frameworks adopted. The data on the observations and histories were analyzed similarly, but were used to support or clarify the participants' statements about the care they provided. To present the interview results, an identification was used, indicating the profession and/ or function, followed by the letter P and a number, corresponding to the inclusion of the interview in ATLAS.ti.
All participants signed two copies of the Free and

Results
The study results are presented in three categories

Care to diabetes patients in Primary Health Care
The large majority of diabetes care was offered collectively, aiming to promote care access to a larger number of users, who were registered in the Registration and Monitoring System of Hypertensive and Diabetic Patients. This was called group care and was organized through quarterly pre-scheduling, favoring this access to the health service and optimizing the professionals' agenda for care delivery to more people with the same disease on predefined dates and times. The dynamics established to hold the groups was care centered on the medical appointment, prescriptive, in which the main activity was to deliver prescriptions and, sometimes, but not systematically, laboratory tests were requested. This moment was marked by a very short period to attend to people, entailing important activity constraints, such as the physical examination.  Another aspect found was the lack of integration between the professionals and the relatives of diabetes patients, as well as with their social context.
It is highlighted that, except for the CHA, no other professional appointed the existence of this engagement and direction in their actions and practices in the care and assistance process for diabetes patients in PHC.

Care to diabetes patients in Primary Health Care: team-management
The professionals perceived motivation, considered as a requisite for self-care, as something distant from the reality of the current care practices for diabetes patients in PHC. In the observation of the group meetings, the diabetic patients remained seated for a long time, passively, awaiting the physician to call them.
Overall, there was no systematic interaction with the professionals and even among them. Another aspect to be considered in this care was the lack of actions that identified the mobilization of social resources, with community orientation, for this cause, as proposed in the MACC.  Concerning the HCN, these were not considered a reality of the municipal health system yet, especially due to their weaknesses in the connections among the different points of the network. The health professionals had no specialized/secondary service for reference and support, with great difficulty to forward the patients as needed to adequate care. In addition, when the specialized consultation happened, the counterreferral was still precarious. The user should bring the prescription from the specialist for the PHCS/FHT professional to continue prescribing the proposed drugs;

Diabetes policies: barriers to applicability
expressing the lack of articulation among the different network points.

Discussion
According to the study results, group care for diabetes patients was marked by activities that were more focused on attending to the demand for medical appointments. This care was not guided by the health policy, indicating only partial compliance with the care policy for diabetes patients (9) . The actions were developed based on the biomedical model, with great distancing from the necessary practices for chronic patients, in accordance with the MACC (7) . Similar situations were also found in other PHC studies, showing that this situation is repeated in different places across the Brazilian reality (10)(11) .
Listening, as an element of welcoming, fundamental to establish bonding and considered one of the pillars of therapeutic action, being fundamental for care integrality (12) , was not evident in this care. Individualized monitoring is recommended for diabetes patients, considering that the context of each patient and the way (s)he lives with the disease are essential for care that is intended to maintain the glucose levels under control and promote patients' quality of life (9,13) .
Orientation, as a health education instrument, is fundamental to allow people to practice self-care (9,(14)(15) , in order to have a healthy and productive life. Studies that analyzed the health practice and health education concepts highlight the need to further value the role of health professionals as drivers of change in health education and in the health model they are inserted in (15)(16) .
The lack of integration between the professionals and the diabetes patients' family, as well as with their social context, indicates the lack of convergence between health care practice and the principles of the Family Health Strategy (FHS), integrality and the MACC, in which the family should be involved in the users' care plan (7) .
Brazilian studies that picture the applicability of the MACC evidence that, after its implementation, care for the people improved, with enhanced treatment compliance by the patients (3) and the introduction of new care strategies by the health professionals, including actions for self-care, motivational interview and operative group (8) . This reality converges with international experiences, in countries that adopted a new specific care model for chronic conditions, which affirm their efficacy and efficiency to assist this population in its singular and plural aspects, expressed in their health-disease processes (6,20) .
As limitations, we register that this study only