Referral to the national network of integrated care: the nurses’ perception

Objective: to understand the referral to the National Network of Integrated Continuous Care, from the perspective of nurses who work in this care context. Method: an exploratory and descriptive study with a qualitative approach, with data collection between July and September 2019 through interviews with 12 nurses who work in Integrated Continuous Care Teams, in Northern Portugal. The content analysis technique was used to analyze the statements. Results: the professionals revealed that there are difficulties and constraints in the process of referring users to the National Network of Integrated Continuous Care. The process is bureaucratic, complex, and time-consuming, conditioning user accessibility to timely care. Conclusion: the referral process is a very bureaucratic and time-consuming procedure, which not only conditions and delays users’ access to the National Network of Integrated Continuous Care network, contributing to the worsening of the clinical status of some patients. The number of professionals is insufficient, inducing the demand for services through urgency. The focus on primary care should seek to improve inequalities in access, compete for more equitable and accessible care, generating more quality in health care.


Introduction
Demographic evolution is characterized by a sharp increase in the older adult population, which is associated with a higher prevalence of chronic conditions and dependence, thus increasing the demand for longterm care (1)(2) . This situation has also led to an increase in the health costs (2)(3) .
The National Network of Integrated Continuous Care ("Rede Nacional de Cuidados Continuados Integrados", RNCCI, in Portuguese) in Portugal, beginning in 2006, aimed at creating integrated responses of social action and health with regard to continuous care following good European practices in this area. However, despite being considered an effective strategy, it shows an insufficient response capacity, representing less than 30% of the current needs and, even less of, the expected future needs (4)(5)(6) . In this context, the Integrated Continuous Care Teams ("Equipes de Cuidados Continuados Integrados", ECCI, in Portuguese) are of particular importance since, in addition to contributing to the increase in responses to a national need, they present themselves as a solution for closer care. Increasing the capacity of these teams is assumed to be an incomparably lesser financial investment effort compared to the increase in the number of inpatient units (4,(7)(8) . For this reason, in recent years, there has been a strong international interest in the development of resolute and cost-effective interventions to support older adults living at their homes, reducing the demand for hospital and institutionalized care (9)(10)(11) .
A number of studies on the quality of health care also point out that an understanding of the organizational issues in the provision of health services is essential to explain variations in care and progress towards continuous quality improvement. Health systems need to maximize their effectiveness and efficiency and those of long-term care, provide continuous assistance in service delivery, and adapt to the needs of the patients.
With the growing economic and financial demand, health professionals are challenged to show that the care provided is of high quality, adequate, appropriate, efficient and effective, producing the best results in the patients (6,(12)(13) . Hence, the shift to a health system focused on individual needs and preferences allows for a new insight into the impact of these policies (10,14) .
The primary care network must become more robust, respond to people's needs and coordinate with other services (10,15) .
Based on this framework, this article is conceptually based on the Nursing Role Effectiveness Model (NREM) (16) which is anchored in Donabedian's Health Quality Model, developed from three concepts: the structure, the process, and the results with regard to quality assistance (16) . The NREM allows for assessing the contribution of nurses to health care, advocating a set of relationships between the variables of structure, process, and results. The structural variables refer to issues related to organizational resources, such as the availability of equipment and the skills of the health care team; the process integrates nurses' interventions and the results those changes in the patient's health status as a result of care provision (17) .
The characteristics in the structure and in the nurses' intervention process will provide changes in the results.
The structure integrates factors related to the patient, the nurse, and the organization. The process integrates autonomous and interdependent interventions, such as team communication, case management, and care coordination. The results consider functional state, selfcare, symptom control, and adverse effects (16) .
This research aims to understand the referral to the National Network of Integrated Continuous Care, from the perspective of nurses who work in this care context.

Method
The research carried out was exploratory and descriptive with a qualitative approach, since it was intended to know the studied phenomenon, i.e., the experiences of the participants, based on the descriptions from the surveyed individuals (18) .
A convenience sample was constituted with twelve nurses from the ECCI in the northern region of Portugal, having as inclusion criterion performing functions in the ECCI for more than 3 years. For the definition of the number of participants, the data saturation criterion was adopted, with the end of the collection phase as the empirical framework of the research was outlined to achieve the objective. One of the researchers went to the units to carry out the interviews that took place between July and September 2019, during the work period, on a day and time scheduled according to the availability of the participants and with institutional consent. The data collection method used was the semistructured interview (19)(20) , through a thematic script whose themes addressed the difficulties and constraints in the patient referral process for the RNCCI network, so a specific order was not followed in conducting the interview, allowing for the conversation to continue and for the spontaneity of the participant (19)(20) , while www.eerp.usp.br/rlae 3 Foseca-Teixeira SA, Parreira P, Mónico L, Salgueiro-Oliveira A, Amado JC. maintaining a focus on the predefined objective. All the interviews were recorded on audio, respecting the ethical assumptions underlying research of this nature. The interviews lasted a mean of 40 minutes and were later transcribed in full to a Word document on the researcher's private computer and analyzed using the content analysis technique (21)(22) aiming at refining subjective content descriptions, in order to objectively highlight the nature and relative strengths of the stimuli.
Such a path allows for the emergence of valid and replicable inferences from the data to the context under study (23) . In this way, the transcribed interviews were read several times to familiarize with the data and to facilitate understanding of the whole.
Content analysis was performed using NVivo ® , respecting the three phases proposed by Bardin (21)(22) : subcategories, and answer indicators. As references, the units of recording and enumeration were considered (24) . The meaning units were extracted, condensed, and labeled with a code according to the objective of the study and organized according to the NREM conceptual model (structure, process, and results). This approach aimed to ensure reliability and to maintain a balance between the authors' prior understanding of the referral process and to assess how the relationship between structure and process variables impacts on the results (25) .
This study was initiated after approval by the Ethics Committee of the Health Center Groups in the northern region of Portugal. All the interviews were conducted in a reserved place, and the signing of the Free and Informed Consent Term was requested, according to the Declaration of Helsinki (26) , and the anonymity of the participants was ensured by assigning an identification code with the letter E ("Enfermeiro" in Portuguese) and a number from 1 to 12.

Results
From analyzing the content of the transcribed interviews, three categories emerged. The "human and material resources" category was the one with the highest number of references (registration and enumeration units) with 26.78% of the total references, followed by the "difficulties and constraints in the referral process" (13.04%) and the "information system" (11.41%) categories.

Human and Materials Resources
In the "human and material resources" category, the testimonials revealed that, regarding assistance responses, the number of professionals in the ECCI is

Information System
In the Information Systems ("Sistemas de Informação", SI, in Portuguese) category, the testimonies revealed that the registration modules of the SI-RNCCI application are complex and extremely time-consuming.
They mentioned that there is irrelevant information and inadequate or not applicable scales for some patients www.eerp.usp.br/rlae 4 Rev. Latino-Am. Enfermagem 2020;28:e3372.
that hinder the adequate elaboration of the processes.
They pointed out that the information described in the notes is often incomplete and inconsistent and that some records are controversial. The participants considered that the requirement to record on two overlapping platforms -SI-RNCCI and SClínico -implies the need to duplicate records and makes referencing less rapid and less easy. They also stressed that it is sometimes difficult to obtain data referring to the family, namely when data on financial income are requested, as shown

Referral Process
The participants stated that, in detriment of the referral for the patients to the ECCI, they were referred to the inpatient services of the RNCCI network, due to the fact that the patients need continuous care and the ECCI schedules are not adequate to their real needs, such as elucidated in the excerpts of the interviews: The referral of the patients also depends on the assessment of the multidisciplinary team, consisting of a physician, a nurse, and a senior social service technician. The team needs to proceed with the preparation of a medical, nursing, and social service report to be presented to the Local Coordinating Team and subsequently validated by the Regional Coordinating Team. Only after completing this procedure will the patient be able to enter an RNCCI unit.
The results of the present research showed that referring patients to RNCCI is a very bureaucratic,

Discussion
The categories that emerged from the analysis of the content of the interviews and the mobilization of the NREM model allow for disclosing aspects related to problems in the structure (S), difficulties alluding to the referencing process (P) with influence on the results (R), also showing a difficulty in articulation in the relations between (S-P-R). The analysis of the relationship among the variables related to structure (human and material resources) and process (information system) showed to have an impact on the results, generating difficulties and constraints in the referral process culminating in loss in the effectiveness and efficiency of users at the RNCCI network. The difficulties displayed in the referencing structure (S) and process (P) culminate in a notable limitation due to lack of access to nursing care (R). It will be urgent to intervene in such factors to create more organized and efficient processes and less bureaucratic, as they are generators of users' inaccessibility to nursing cares. Some research studies carried out within the scope of long-term care based on the NREM indicates that the nurses' experience (structure) and the independent nursing interventions (process) were significantly related to functional status, symptom control and better patient clinical outcomes (results) (16,27) .
The results of the present research show that referencing is a very bureaucratic and time-consuming (process) procedure, which substantially conditions and delays the accessibility of the patients to the RNCCI network, preventing the patients from having access to timely care (results). This constraint is aggravated by the fact that it is mandatory to integrate three different professionals, requiring validation by two entities (one local and another regional), further aggravated by the mandatory validation by social security, regarding the determination of exemptions and payment of fees.
The bureaucratic process between the UF and the local coordination teams prevents the process from being possible causes for hospitals to under-refer to the RNCCI network and to refer patients to their homes the fact that they do not prolong hospital stay and, consequently, reduce the costs of hospital care. They state that this procedure causes a delay in the patient's admission in due time due to the constraints of the UF. The constraints referred to in this study were also referred to by other studies that assess patient accessibility to the RNCCI network (28)(29)(30)(31) .
The delay in the referral process, in addition to conditioning the patients' admission, also worsens their clinical condition so, at the time of admission, the necessary response may no longer fall within the scope of the ECCI. In addition, associated with the insufficient number of professionals, namely physicians, they culminate in the lack of close monitoring of the patients, which leads to the demand for emergency services. The results of this study are corroborated by other authors who report that patients without a close follow-up resort to the emergency department more frequently, despite the fact that hospitalizations are not only expensive, but are also potentially harmful to the health of the older population (31)(32)(33)(34) , therefore contrasting with the recommendation of the Organization for Economic Cooperation and Development, which estimates that 30% of the hospital activity in Portugal could be done in the community (3) .
The results of this research demonstrated regional inequalities in access to health care provided by the ECCI, which is why it is necessary to adjust the number of vacancies allocated according to population density, as well as to increase human and logistical resources, namely transportation, so that there is greater equity between access to health care and more efficient use.
These results are also corroborated by some studies that report that there is an inequity in access to the RNCCI network, and regional geographic dispersion with some degree of randomness due to its location. In addition to being more accessible due to proximity, ECCI also generate lower financial costs, although they continue to be largely underutilized throughout the country (3)(4)(35)(36) .
Thus, we consider it important to increase the awareness of the hospitals and of the primary care network for the referral of patients to the ECCI. Now we verify that health care currently takes place in a fragmented environment, which is why it is necessary to provide continuous and coordinated care centered on people (36)(37) where accessibility to the ECCI is an advantageous option. Promoting equity in access to health care and a more efficient use of the available resources are fundamental aspects for improving the health status of the population, especially the older adults. Increasing the response capacity of the ECCI is assumed to be an incomparably lesser financial investment effort due to the increase in the number and types of hospitalization, so that more attention should be placed on primary care, as it improves the quality of health care and reduces inequalities in access, generating more equitable and accessible cares. Such bet is reflected, in addition to the health results in the population, in a reduction in the total cost of care, obtaining results at a more accessible and sustainable cost (3,5,15) . Health systems need to maximize their effectiveness and efficiency of health services and longterm care, providing continuous care between services, providing important improvements in the quality and accessibility of the users, adapting to their care needs (5,(13)(14)(15) .
A number of studies carried out in the context of outpatient care have shown that nursing interventions have contributed to improving the results of the patients (27) . NREM has the potential to identify specific results generated by the care provided by nurses, highlighting the role and responsibility of the Nursing profession, and justifying its importance in making decisions about health policies (16) .
The research allowed identifying and understanding the difficulties and constraints in the referral process of patients who need long-term care to the RNCCI network.
It also contributes to assist the management in decision making, namely in the improvement of strategies and tools with a contribution to ensuring the improvement of quality in the continuity of care and the reduction in the number complications and in the worsening of the user's health due to lack of care because of non-referrals.
Although the research has achieved its objective, it is understood as a possible limitation the fact that the research took place only in the northern region, which does not mean that the reality presented is similar in other regions of Portugal, being unwise to generalize the results.

Conclusion
The results of this research revealed that the referral process is a very bureaucratic and time-consuming procedure, which substantially conditions and delays the accessibility of the patients to the RNCCI network, preventing the users from having access to care in a timely manner. The lack of professionals is evident, which creates difficulties in monitoring the patients' proximity, thus inducing the demand for emergency services. The delay in the referral process, in addition to being able to condition the patients' admission, also worsens their clinical conditions. The health team professionals highlighted the need for systematic and timely access to records. www.eerp.usp.br/rlae 7 Foseca-Teixeira SA, Parreira P, Mónico L, Salgueiro-Oliveira A, Amado JC.
Promoting equity between access to health care and its more efficient use, taking into account the available resources, is a fundamental aspect for improving the health status of the population, especially the older adults. Thus, it is considered crucial to create conditions to improve the structural (increase the response capacity of the ECCI, namely with the reinforcement of professionals) and process (simplify the referral process, enable systematic and timely access to data, and improve interoperability in information systems improving care monitoring and evaluation) variables to obtain better results (fewer inequalities of access, more equitable and accessible care). Thus, this research presents itself as a humble but valid contribution to the improvement in the referral and quality of health care to be provided to the users.