In search of network attention: contributions of a multiprofessional residency program in the hospital context

Abstract

Introduction

The Unified Health System considers that hospital care is important for the construction of integrality. Residents in a Multi-professional Residency Program to the Hospital Universitário da Universidade de São Paulo indicated, difficulties of the medical and nursing staff were identified to detecting demands for rehabilitation at hospital discharge, which encouraged residents to create a support group to hospital discharge.

Objective

To verify the sociodemographic and health profile of users accompanied by the support group, identify challenges for insertion of these users in the rehabilitation care network and identify strategies of the support group to face these challenges.

Method

Retrospective, exploratory and descriptive study, based on the documentary analysis.

Results

We analyzed forms of 251 users, 83 (33%) received a referral for rehabilitation at discharge and 17 (6.7%) received referral after guidelines of the discharge support group; 95 (37.8%) sought rehabilitation services. Of these, 60 were effectively included in the services, of which 46 (18.3%) were extra-hospital, such as rehabilitation centers, basic health units and 14 (5.6%) in the Hospital Home Care Program. Concerning professional areas, 34 (13.5%) started physical therapy treatment, 29 (11.6%), speech therapy and 11 (4.9%), therapeutic-occupational. It was identified insufficiency of professional referrals and difficulties of users regarding access and continuity of care. To cope with challenges, the support group has reinforced prescribed referrals or directed obtaining referrals in medical consultations on the network.

Conclusion

The group has tried to understand user demands by professional area, oriented users to access services and to get treatments. The users have valued the receptiveness of the support group, being a strategy to promote integral health care.

Keywords:
Patient Discharge; Comprehensive Health Care; Speech, Language and Hearing Sciences; Physical Therapy; Occupational Therapy; Rehabilitation

Resumo

Introdução

O Sistema Único de Saúde considera o cuidado hospitalar como importante eixo para a construção da integralidade. Os residentes do Programa de Residência Multiprofissional, do Hospital Universitário da Universidade de São Paulo, identificaram dificuldades da equipe médica e de enfermagem em detectar demandas em reabilitação na alta hospitalar, levando residentes a criarem um grupo de apoio à alta.

Objetivo

Verificar o perfil sociodemográfico e de saúde dos usuários acompanhados pelo grupo de apoio, identificar os desafios para inserção dos usuários na rede de serviços de reabilitação e as estratégias do grupo de apoio para enfrentamento desses desafios.

Método

Estudo retrospectivo, exploratório e descritivo, baseado em análise documental.

Resultados

Foram analisados formulários de 251 usuários, 83 (33%) receberam encaminhamento para reabilitação por ocasião na alta hospitalar e 17 (6,7%), a partir das orientações do grupo de apoio à alta; 95 (37,8%) procuraram serviços de reabilitação. Desses, 60 foram efetivamente inseridos em serviços, sendo 46 (18,3%) extra-hospitalares, como centros de reabilitação e unidades básicas de saúde, e 14 (5,6%) no Programa de Atendimento Domiciliar do hospital. Quanto às áreas profissionais, 34 (13,5%) iniciaram tratamento fisioterápico, 29 (11,6%), fonoaudiológico e 11 (4,9%), terapêutico-ocupacional. Identificaram-se insuficiência de encaminhamentos profissionais e dificuldades dos usuários quanto ao acesso e continuidade de atenção.

Conclusão

O grupo de apoio tem reforçado encaminhamentos prescritos ou sua obtenção em consultas médicas na rede, acolhido demandas por área profissional, orientado usuários para acessar serviços e inserir-se em tratamentos. Os usuários valorizaram a escuta e o acolhimento do grupo de apoio, no qual se configuram estratégias para promoção do cuidado integral em saúde.

Palavras-chave:
Alta do Paciente; Assistência Integral à Saúde; Fonoaudiologia; Fisioterapia; Terapia Ocupacional; Reabilitação

1 Introduction

Since the creation and implementation of the Unified Health System (SUS), the structuring and operation of services oriented by the integrality of care have been sought, implying an articulated set of actions at different levels of complexity, according to the demands of the patient (BRASIL, 1990). Also, services should provide access conditions and be resolvable in the problems and risks that affect the quality of life of the population (BRASIL, 2009), developing actions to promote health, to prevent risk factors, to assist to damages and rehabilitation according to the health-disease process (FRATINI; SAUPE; MASSAROLI, 2008).

Hospital care is considered an important axis for the construction of the integrality, necessary to seek it in the hospital and from the hospital (CECILIO; MERHY, 2003). In this construction of integrality from the hospital, it is sought to offer care in a wide service network (CECILIO; MERHY, 2003), with overcoming the fragmentation of knowledge and practices. In this perspective, the service network is characterized as a circuit, in which the hospital is considered a fundamental component to ensure the integral care for the patient (CECILIO; MERHY, 2003).

However, there are shortcomings between the hospital and the basic care due to factors such as fragmentation of care, especially in the hospital setting, focused on the specialty (PEREIRA et al., 2014) and insufficient rehabilitation services (TOLDRÁ; SOUTO, 2013; RODES et al., 2017), compromising the care network (BRASIL, 2012a; VAN STRALEN et al., 2008).

The multi-professional residences and the professional health area are public policies that induce the education at the work and for the work in the SUS. Through teaching-service-community, it is aimed at training workers to offer integral, multi-professional and interdisciplinary care (BRASIL, 2012b). The importance of inserting Occupational Therapy into training programs of this nature is highlighted since, besides the opportunity for training, it enables to recognize the contribution of Occupational Therapy in the service and in the teamwork.

In this context, since 2012, the University Hospital to the Universidade de São Paulo (HUUSP) receives professionals in the Program of Multiprofessional Residency in Health Promotion and Care in Hospital Care - Adult and Elderly concentration area in Physical Therapy, Speech Therapy and Occupational Therapy (RMP Program), being a field of practical training of undergraduate and postgraduate students from different areas.

In the HUUSP, specifically in the nursing area of the medical clinic (NMC) in the discharge of hospitalized adults and elderly people, residents of the RMP Program have found difficulty in interaction and communication by the medical and nursing staff. Also, these teams have difficulties to identify the needs of rehabilitation patients in the Physical Therapy, Speech Therapy and Occupational Therapy areas. Although the NMC receives students and residents of different professional areas, the discharge in this service does not have the participation of rehabilitation professionals, except when the medical and nursing staff requests it.

The “Multi Assistance Group for Discharge” (GAAMA) was developed in 2013, under the RMP Program to contribute to the referral and insertion of patients in the rehabilitation services network, consisting of residents of the three professional areas with teacher's mentorship of the Program. GAAMA states that the production and sharing of knowledge in everyday hospital care and co-responsibility for care can transform the action of professionals into teamwork (BRASIL, 2011).

GAAMA tries to favor referral and counter-referral mechanisms, that is, referrals to services of greater and lesser complexity, respectively, through telephone follow-up of patients after hospital discharge, for a year, in predefined periods. Thus, GAAMA seeks to promote integrated care for patients with demands for rehabilitation.

The objectives of this study were: to verify the sociodemographic and health profile of the patients monitored by GAAMA, to identify possible challenges for the insertion of these patients into the network of rehabilitation services and strategies used by GAAMA residents in the areas of Physical Therapy, Speech Therapy and Occupational Therapy for their coping.

2 Method

This is a retrospective, exploratory and descriptive study, specifically based on documents analysis for patient follow-up forms at GAAMA developed at the HUUSP. Documentary research is characterized by the use of materials that did not receive an analytical treatment (GIL, 2008). These materials include records in electronic forms, medical records, and other documents.

These forms were elaborated by the residents based on the Ordinance that creates the Care Network for the Person with Disability at SUS (BRASIL, 2012a) and on the principles and strategies described in the document called Cadernos Humaniza SUS (BRASIL, 2011) regarding multidisciplinary work, reception and humanization of care, and the hospital's contribution to care network.

The patients who needed rehabilitation were contacted by telephone at the NMC and asked to inform them about rehabilitation referrals received at the time of discharge and possible insertion into rehabilitation services. Those who were not yet in attendance were invited to keep a telephone follow-up to be assisted in this process. Thus, the data collection took place after completing a follow-up form, which was done by telephone contact, during one year after their discharge, at predefined periods of 15 days, 45 days, 3 months, 6 months and 1 year. In the case of 3 unsuccessful contact attempts, during 3 weeks, the patient of the support group was disconnected and registered in the form. For this documentary study, forms of all patients monitored by GAAMA between December 2013 and June 2017 were selected.

The following information was extracted from the summary of hospital discharge referring to the following data: sociodemographic data (age and gender), health (diagnosis - ICD10), hospitalization (days), conditions and procedures related to hospital discharge, basic reference unit. There were no data on medical referral for rehabilitation in the discharge summary probably because, in medical training, this information is not considered relevant to its operation in the hospital.

Information on the inclusion or not in the rehabilitation services network of the patients, difficulties related to this insertion, and guidelines given in response to these difficulties were also recorded through telephone follow-up. Thus, the adequate insertion of the patient in the network was ensured through the following actions: 1^st - to obtain information from the patient about possible medical referral for rehabilitation, for the Physical Therapy, Speech Therapy and Occupational Therapy areas, on the of discharge or provide guidance to the patient to look up a BHU reference to obtain it, considering that often this referral was not performed; 2^nd - to survey about the demands for a rehabilitation by the professional area: for Physiotherapy, aspects related to gait, balance, postural transfers, fatigue, pain, and breathing difficulties were identified; for Occupational Therapy the participation and barriers in the accomplishment of the activities of self-care, work and leisure were investigated; in Speech therapy, they were asked about swallowing, speech and communication functions; 3^rd – to identify if there was a demand for the service they were sent; 4ª) to see if it was possible to schedule the indicated therapy; 5) to check if the treatment was started and 6) to know the patients´ opinion about the GAAMA assistance, for the insertion in the services network and about the guidelines for their demands in rehabilitation. This action was specifically to those who were enrolled in rehabilitation services or who completed follow-up by GAAMA within a year. These actions were not necessarily developed in all telephone contacts established with the patient, and also correspond to the specific moment of the patient in the process of monitoring by GAAMA. The residents of the areas of Physical Therapy, Speech Therapy, and Occupational Therapy were guided about the objective of GAAMA and the application of the form during a telephone call. The telephone contact with the patients was carried out in the periods described above and at different times for its feasibility.

The sociodemographic, health, hospitalization, search and insertion data in the rehabilitation services were submitted to a descriptive analysis with the production of absolute and relative frequencies. Information about patients´ experience and the guidance provided by the residents was organized and analyzed qualitatively.

The study was approved by the Research Ethics Committee of Medicine Faculty of the USP, through process number 199/16, according to Resolution 466/2012 of the National Health Council.

3 Results and Discussion

Completed forms were analyzed through a telephone follow-up of 251 patients attended by GAAMA at the HUUSP. Most of them were elderly people equally distributed by gender. The most frequent diagnoses were cardiovascular and respiratory diseases, especially stroke, as can be observed in Table 1.

Table 1
Sociodemographic and clinical characteristics of patients monitored by GAAMA between December 2013 and June 2017.

Variable	Categories	N (%)
Age	< 60 years old	85 (33.86)
	≥ 60 years old	166 (66.13)
Gender	Female	126 (50.19)
	Male	125 (49.80)
ICD-10	Cardiovascular diseases	95 (37.84)
	Respiratory diseases	64 (25.49)
	Blood and hematopoietic organs diseases and some immune disorders	21 (8.36)
	Genitourinary diseases	17 (6.77)
	Neoplasms	15 (5.97)
	Nervous system diseases	13 (5.17)
	Endocrine, nutritional and metabolic diseases	9 (3.58)
	Other diseases	17 (6.77)
Length of hospital stay	1 - 5 days	39 (15.53)
	6 - 10 days	86 (34.26)
	11 - 20 days	73 (29.08)
	> 20 days	53 (21.11)

Half of the patients remained hospitalized for more than 11 days, considered as an extended period since admissions with more than 12 days are estimated as long-lasting hospitalizations (PARDO; GARCIA; CORTÉS, 2016). However, the hospitalization period has been decreasing, given the advance of the medical sciences and the high cost generated by hospitalizations (SOUSA; SILVA; GUIMARÃES, 2008).

In this sense, the time of hospitalization of the patients in the study indicates a need for a plan of action, from the beginning of the hospitalization, aiming at the planning for high discharge, and the continuity of care after hospital discharge (DELATORRE et al., 2013; BRITTON; ROSENWAX; MCNAMARA, 2015). Although historically the hospital is considered a space for treatment and cure (SILVA et al., 2011), this service plays a fundamental role in the production of integral care and in the articulation with the service network since the professionals do not just perform the counter-reference as a purely bureaucratic act at the time of discharge (MALTA; MERHY, 2010).

Therefore, referral and counter-referral is more effective in the hospital discharge process when they occur from a multi-professional planning, in which the patients receive information and clarification about their health condition and become more appropriate about the care to be followed. Thus, discharge planning is an indispensable tool for comprehensive care during hospitalization and post-discharge. This includes the identification of the patients´ needs and health resources available in the network (WONG et al., 2011), demanding a multi-professional action (DELATORRE et al., 2013). Also, teamwork in hospital care suggests the sharing of knowledge and practices for the construction of an integral and humanized work (BRASIL, 2011).

Although the HUUSP is characterized as a school service, the discharge is still defined by the medical team and carried out by the nursing and social assistance team. The lack of shared action, involving the areas of Physical Therapy, Speech Therapy and Occupational Therapy, caused many patients to be discharged from the hospital without a re-hospitalization referral. Thus, only 83 (33%) of the 251 patients monitored by GAAMA had received a referral for rehabilitation treatment in one or more professional areas. This situation compromised the multi-professional nature of the hospital care and the co-responsibility between the different professionals in the various moments of care, as provided by SUS (BRASIL, 2011).

Based on GAAMA guidelines, 17 (6.7%) patients received referrals, totaling 100 (39.7%) patients with referrals for rehabilitation. Ninety-five of them (37.8%) sought rehabilitation services. Qualitative information was not systematically recorded in these forms, thus, they were analyzed only when available. The information was categorized according to the items contained in the form and actions foreseen by GAAMA: a) factors related to the difficulties of access and insertion of patients to the services, b) guidelines for patients to deal with difficulties, c) support for qualified rehabilitation demands, d) patients’ opinions regarding the follow-up.

Regarding the factors related to the difficulties of access and insertion of patients to the services, 20 (21%) records were identified: 1 record (1%) mentioned the distance between the residence and the service; 1 record (1%) reported the unavailability of free transportation provided by the municipality; 2 records (2.1%) indicated the absence of answers from the services to book a consultation; 7 records (7.3%) reported disagreement in the service’s doctors in conducting referrals to rehabilitation areas due to lack of demand; 2 records (2.1%) mentioned that they did not seek care at the BHUs because of their disbelief in obtaining it and/or the lack of professionals to attend; 3 records (3.1%) reported a service strike, 3 records (3.1%) indicated a lack of request by the referral patient at the medical consultation, and 2 records (2.1%) stated that the hospital referral was not recognized by the service.

Also, the patients of the West Zone of the city São Paulo can show difficulties of access to health and rehabilitation services due to the lack of rehabilitation services in the region (TOLDRÁ; SOUTO, 2013; RODES et al., 2017), compromising the care network (BRASIL, 2012a; VAN STRALEN et al., 2008).

However, the process of using the health services goes beyond the organization of offer, affecting factors related to patients and their support network, such as: health needs (morbidity and severity of the disease), age, gender, income, education, housing region (TRAVASSOS; MARTINS, 2004) and family, economic and labor organization (TOLDRÁ; PEREZ; MATTA, 2000). Also, 13 (13.6%) patients were not present, resulting from functional limitations for transportation mentioned in 2 (2.1%) records; lack of a companion, showed in 2 records (2.1%); restriction of financial resources, shown in 2 (2.1%) records; non-attendance at the scheduled medical appointment reported in 3 records (3.1%), and the perception of the absence of demand in rehabilitation due to the improvement of the functional condition, mentioned in 4 (4.2%) records.

The guidelines for patients to deal with difficulties are the identification and ways of accessing to a BHU reference and/or other relevant services, both inside and outside the territory; procedures required for scheduling the transportation service of the municipality; request for a referral for rehabilitation during the medical consultation in the network. The patients were also supported and guided to seek the hospital's ombudsman so it can intercede in favor of the patient with the service to recognized the referral made at the time of discharge.

For the patients who obtained a referral for rehabilitation during discharge or medical consultation performed on the network, GAAMA raised the demands in the areas of Physical Therapy, Speech Therapy, and Occupational Therapy, seeking to understand and accommodate specific needs to support the qualified insertion to the rehabilitation demands.

According to Figure 1, 46 (18.3%) of the 95 (37.8%) patients who actually sought the services were placed in extra-hospital rehabilitation services and 14 (5.6%) were placed in the Home Care Program of the HUUSP. Thus, 60 patients were effectively included in the services, and 34 (13.5%) started attending Physical Therapy, 29 (11.6%) attending Speech Therapy and 11 (4.9%) attending Occupational Therapy. The patients who had a referral for two or three professional areas did not always get care for all due to lack of space or lack of professionals in the services.

Figure 1
Referral and insertion of patients monitored by GAAMA in the rehabilitation services network between December 2013 and June 2017.

Most patients were sent to the services linked to the university, followed by the Basic Health Units, Specialized Rehabilitation Centers, services linked to other hospitals and to the private network.

In the Speech Therapy and Occupational Therapy areas, university services were the ones having most of the patients, while the Physiotherapy care was more frequently provided by the Basic Health Units. This reality corresponds to the differences in the number of professionals hired in in the area of Occupational Therapy (RODES et al., 2017).

In a total of the 15 (15.8%) who patients that responded the opinions about GAAMA follow-up, 14 (14.7%) acknowledged that they had been heard and oriented about their demands on rehabilitation. Only one patient (1%) did not identify benefit in the follow-up.

From these records, the follow-up offered by GAAMA such as host can be understood. According to Guerrero et al. (2013), this hosting can be done through listening and guidelines, becoming strategic for the qualification of health care. Pimentel and Coelho Junior (2009) indicated that the hosting is active and empathic listening, and may result in modifications in the patients’ experience. Also, the hosting expressed in “being with” and “being close to” is one of the most important guidelines for SUS (BRASIL, 2010).

A study with the interviews of thirty-three patients of two basic health units in Porto Alegre showed that although they identified problems related to access, active listening and resolution of actions were mentioned as some of the factors responsible for satisfying their demands (LIMA et al., 2007).

Of the 251 forms analyzed, the GAAMA guidelines were not provided in 61 (24.3%) patients due to the impossibility of telephone contact during the follow-up, 58 (23.1%) did not mention demands for rehabilitation, 23 (9.2%) died and 18 (7.2%) did not continue the follow-up after one year, as established by the program. GAAMA's withdrawal also occurred due to other reasons, as identified in 31 (12.6%) forms, such as long-stay institution (LSI) enrollment in 5 (2%) forms; hospitalization, mentioned in 9 (3.6%) records, change of residence to another state, present in 4 (1.6%) forms, being in a street situation, identified in 2 (0.8%) and lack of availability to participate in GAAMA, or lack of the patient´s interest in rehabilitation, recorded on 11 (4.4%) forms.

The failure in the telephone contact could have been lessened if the number conference occurred during the hospital discharge process. On the other hand, the absence of perception of demand can be related, in fact, to the probable improvement in the general state and functionality of some patients after hospital discharge. According to Mafra (2012), the progressive improvement in the quality of life and functionality of 75 hospitalized patients submitted to mechanical ventilation during hospitalization was measured by telephone, using standardized questionnaires at 30, 90 and 180 days after hospital discharge. Thus, the lack of demand for rehabilitation can be related to better self-perception of health that involves the perception of the ability to perform some tasks, functional status and health (TEIXEIRA; NERI, 2008).

The results obtained through the analysis of the records allow affirming that the insertion of patients into the rehabilitation network was partial. The actions of GAAMA carried out after hospital discharge to broaden the identification of demands and favor their attention in the network, should be complemented by others to be undertaken even during the period of hospitalization. In this perspective, GAAMA residents have sought to sensitize professionals through informal conversation and information exchange during the hospital routine, to act as a team in the attention to patients with demands in rehabilitation and for referrals to the service network at the moment of discharge from the hospital. GAAMA has also leveraged the referral and counter-referral process from the hospital, sharing the dynamics of the functioning of the services or even establishing direct contact with the Basic Health Units, Specialized Rehabilitation Center and adapted transportation services. Thus, GAAMA and the NMC Program as a proposal for interprofessional education has provided opportunities for joint interactions and interventions of the different professional areas. They are the collaborative practices (FRENK et al., 2010) and the possibilities of building a more collective action (PEDUZZI et al., 2013).

4 Conclusion

The analysis of the records of the patients´ follow-up by GAAMA allowed to identify challenges for the patients´ insertion and to gather strategies adopted for their confrontation. The records indicated important gaps in the processes of referral of patients to the services network, from the inadequacy of the referrals by the professionals of the hospital to the difficulties of the patients in the access and continuity of the care network. As strategies to circumvent these difficulties, GAAMA has strengthened prescribed referrals, guided referrals in consultation with doctors in the network services, welcomed patients in their specific demands for rehabilitation, guided patients regarding procedures for accessing services and favored their insertion to the indicated treatment.

Qualified listening and guidance provided by residents of the Physical Therapy, Speech, and Occupational Therapy areas of GAAMA have been recognized and valued by the patients. Thus, GAAMA is considered relevant for the reception, promotion of comprehensive health care for patients with demand for rehabilitation within the region, and for the expansion and consolidation of the care network for them from the hospital.

The limitations of the study were that there were failures in the registration of information of a qualitative nature, hindering to analyze the totality of the aspects involved in the patients’ experience in their follow-up process by GAAMA. These failures have been identified in GAAMA work oversight and the quality of the records have been improved. New studies could continue the analysis of the records, which would allow the extension and deepening of the investigation about facilitating factors and difficulties in the processes of insertion of the patients in the services and ways of improvement of GAAMA.

Acknowledgements

We thank the support given by the Fundação Faculdade de Medicina of the University of São Paulo.

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Publication Dates

• Publication in this collection
  26 Sept 2019
• Date of issue
  Jul-Sep 2019

History

• Received
  28 Feb 2018
• Reviewed
  04 Oct 2018
• Reviewed
  06 Feb 2019
• Accepted
  10 Apr 2019