Primary Health Care Portfolio: Assuring of integrality in the Family Health and Oral Health Teams in Brazil

Cunha, Carlo Roberto Hackmann da; Harzheim, Erno; Medeiros, Olivia Lucena de; D’Avila, Otávio Pereira; Martins, Caroline; Wollmann, Lucas; Faller, Lívia de Almeida

doi:10.1590/1413-81232020254.31862019

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ARTICLE • Ciênc. saúde coletiva 25 (4) • Mar 2020 • https://doi.org/10.1590/1413-81232020254.31862019 copy

Primary Health Care Portfolio: Assuring of integrality in the Family Health and Oral Health Teams in Brazil

Authorship SCIMAGO INSTITUTIONS RANKINGS

Abstract

More than 30 years into the anniversary of the Unified Health System (SUS), 40 years after Alma-Ata, and soon after the Astana Conference, the Brazilian Ministry of Health proposes several strategies to strengthen PHC with the creation of the Primary Health Care Secretariat (SAPS). This paper presents the process of developing the national PHC service portfolio, one of the strategies developed by SAPS to strengthen the PHC clinic, and the challenges for the expansion of comprehensive care in the actions developed by the Family Health and Oral Health teams. After the public consultation, from a total of 209 initially listed actions and procedures, including incorporations and exclusions, 210 items were defined, including the actions planned for the integration between primary care and health surveillance. We emphasize that the national portfolio model can be adapted to the reality and municipal context in each of the federation units, including considering the availability of the local care network.

Key words
Primary health care; Comprehensiveness; Family health; Oral health; Brazil

Level of agreement	(%) of services pointed out for inclusion
Level of agreement	Adult and Elderly	Child and Adolescent	Procedures in PHC	Oral Health	Overall portfolio of services
> 90%	93.0	94.0	45.0	78.0	77.6
80-89.9%	3.0	6	35.0	22.0	16.6
70-79.9%	2.0	-	20.0	-	5.4
< 60%	2.0	-	-	-	0.4

	Adult- and elderly-centered attention and care
1	Prenatal care for pregnant women and their partners, using the Pregnant Woman's Handbook.
2	Postpartum care.
3	Women care during the climacteric period.
4	Approach to sexual and reproductive health: individual and group guidance on contraceptive methods; risk management; offering and dispensing preventive supplies and rapid tests; sexual dysfunctions; preconception assessment; early pregnancy diagnosis and guidance on marital infertility.
5	Management of the most common gynecological problems: abnormal uterine bleeding, fibroids, vaginal discharge (syndromic approach), and pelvic pain.
6	Prevention, identification, reception, and monitoring of situations of violence against women, sexual, intra-family, and gender violence, preferably in intersectoral partnership with social assistance and public security services.
7	Promotion of breastfeeding and management of common breast problems related to lactation.
8	Screening for cervical cancer and monitoring of women diagnosed with cervical cancer.
9	Screening for breast cancer and monitoring the person diagnosed with breast cancer.
10	Monitoring of adults and elderly in palliative care, with guidance to family members/caregivers.
11	Assistance to vulnerable populations, such as people living in the streets, gypsy, quilombola, people deprived of liberty, among others.
12	Monitoring of people with work-related diseases.
13	Epidemiological analysis of the local health situation.
14	Performing notifications and health surveillance actions.
15	Home care for people who are restricted to bed/bedridden, with no mobility, as well as in situations with an indication of home evaluation after death, or resistance to treatment.
16	Home care for older adults restricted to the home or with mobility difficulties, including information, health guidelines, counseling, and support for relatives/caregivers.
17	Identification and monitoring of vulnerable older adults, at risk of functional or fragile decline (multimorbidities, polypharmacy, recent hospitalizations, sphincter incontinence, recurrent falls, changes in gait and balance, cognitive impairment, sensory impairment, unintentional weight loss, difficulty in chewing or swallowing, signs and symptoms of mood disorders, family insufficiency, social isolation, suspected violence, degree of dependence for activities of daily living) with the establishment of a care plan adapted to each case.
18	Prevention, identification, reception, and monitoring of situations of violence against older adults, preferably in intersectoral partnership with social assistance and public security services.
19	Prevention of domestic accidents, falls, and fractures.
20	Promotion of active and healthy aging.
21	Prevention, identification, treatment, and monitoring of nutritional disorders in adults and older adults.
22	Screening and counseling for drug abuse and polypharmacy.
23	Immunization as per the vaccination schedule of adults and older adults, watching for situations of outbreaks of vaccine-preventable diseases and specific clinical situations.
24	Identify and accompany adults and older adults in social assistance or social benefits programs.
25	Promoting the adoption of healthy lifestyle habits, such as adequate and healthy food, body practices and physical activities, control of alcohol, tobacco, and other drugs, among others.
26	Prevention, active search, diagnosis, treatment, and monitoring of people with leprosy.
27	Prevention, screening for respiratory symptoms, diagnosis, treatment, and monitoring of people with Tuberculosis (first-line treatment, directly observed treatment, screening for respiratory symptoms, and search for contacts of patients with pulmonary tuberculosis).
28	Prevention, identification, and counseling regarding the abuse of alcohol and other drugs.
29	Prevention, identification, counseling, and treatment concerning tobacco use.
30	Prevention, screening, diagnosis, treatment, and monitoring of people diagnosed with Syphilis, Viral Hepatitis, other STIs, and people living with HIV, with special attention to key populations.
31	Promotion of responsible and active parenting.
32	Screening for colon and rectum neoplasia in people between 50 and 75 years old.
33	Tracking and monitoring of DM2 in asymptomatic adults.
34	Global Cardiovascular Risk (GCVR) screening and identification based on age, gender, clinical history of cardiovascular manifestations, physical examination focused on manifestations of atherosclerosis, blood pressure measurement, abdominal circumference, weight, height, and BMI; for people aged 40 or over or indeterminate risk indicators request for total cholesterol, HDL cholesterol and fasting glycemia aiming at achieving the GCVR Stratification Score.
35	Identification, management, and monitoring of people with Diabetes Mellitus (DM).
36	Identification, management, and monitoring of people with Systemic Arterial Hypertension (SAH).
37	Management of cardiovascular diseases: peripheral arterial disease, atherosclerotic disease, chest pain, heart failure, palpitations and chronic arrhythmias, varicose veins, post-thrombotic syndrome.
38	Management of the most prevalent endocrinological conditions: hypothyroidism, hyperthyroidism, thyroid nodules, obesity, dyslipidemia.
39	Management of people with intestinal parasites.
40	Management of people with exposure and problems to neglected diseases, such as rabies, Chagas disease, schistosomiasis, leishmaniasis (visceral and cutaneous), trachoma, malaria.
41	Management of arboviruses (dengue, Zika, yellow fever, and chikungunya).
42	Management of the most prevalent conditions of the digestive system: dyspepsia, gastroesophageal reflux, changes in bowel habits, gastroenteritis, hemorrhoids, and other orifices, abdominal pain, fatty liver, liver laboratory changes.
43	Management of the most prevalent chronic respiratory diseases: Asthma, COPD, chronic cough, obstructive sleep apnea, dyspnea, pulmonary nodules.
44	Management of the most common neurological conditions: headache, dementia syndromes, carpal tunnel syndrome, epilepsy, stroke, Parkinson's disease, vertigo, facial paralysis.
45	Management of the most prevalent musculoskeletal conditions: low back pain, neck pain, osteoarthritis, shoulder pain, bursitis/tendinitis, hip pain, hand/wrist problems, knee pain, ankle, and foot pathologies, temporomandibular disorders (TMD), fibromyalgia, osteoporosis, gout.
46	Management of the most prevalent genitourinary conditions: chronic kidney disease (chronic kidney patients not transplanted), urinary tract infection, kidney stones, benign prostatic hyperplasia, urinary incontinence.
47	Management of the most prevalent hematological conditions in PHC: anemia, sickle cell anemia, peripheral lymph node enlargement, leukopenia, leukocytosis, thrombocytopenia, thrombocytosis.
48	Management of the most prevalent dermatological conditions: acne, cellulite, dermatitis, erysipelas, scabies, wounds, furuncle, herpes simplex, herpes zoster, hyperhidrosis, intertrigo, larva migrans, mycoses, miliaria, nevi, pediculosis, pyoderma, nail diseases, psoriasis, tungiasis, hives, warts.
49	Management of the most prevalent ophthalmological conditions: conjunctivitis, hordeolus, and chalazion, pterygium, and blepharitis.
50	Management of the most prevalent otorhinolaryngological conditions: vertigo, rhinosinusitis, otitis, hearing loss, bacterial tonsillitis, nasal obstruction, sleep apnea, labyrinthtopathy, epistaxis.
51	Management of the most prevalent diseases in Allergy and Immunology: allergic rhinitis, allergic eczema, urticaria/angioedema, allergy to insect bites, food allergies, drug allergies.
52	Identification and management of the most prevalent psychiatric conditions: emotional suffering and sadness, depressive and anxiety disorders, obsessive-compulsive or post-traumatic disorders, substance use disorders (alcohol, tobacco, and illicit drugs), attention deficit disorder/hyperactivity, psychotic disorders, and suicide and self-mutilation prevention actions.
53	Provision of Integrative and Complementary Practices in comprehensive care for Adults and Older Adults.
54	Issuance of medical certificates and reports, including death certificates, when requested and indicated.
	Child and adolescent-centered attention and care
55	Visit for monitoring the child's growth and development (weighing, measuring, and evaluating development by recording it in the child's handbook).
56	Promotion and support for exclusive breastfeeding for up to 6 months and continued breastfeeding for up to 2 years or more and management of lactation-related problems.
57	Promotion of healthy eating habits.
58	Advice on introducing complementary feeding to the child, as per the current guidelines.
59	Immunization as per to the Child and Adolescent's Vaccination Calendar, guidance to parents or guardians, evaluation and monitoring of the vaccination situation, and active search for absentees.
60	Prevention, identification, treatment, and monitoring of situations related to nutritional disorders (underweight, malnutrition, overweight, and obesity).
61	Child health screening: neonatal screening (foot test and red reflex) and early identification of heart murmurs.
62	Performing notifications and health surveillance actions.
63	Epidemiological analysis of the local health situation.
64	Surveillance of at-risk/vulnerable newborns based on the records and reports supplied by maternity hospitals.
65	Nutritional supplementation (vitamins, minerals, formulas) - when indicated.
66	Prevention, active search, diagnosis, treatment, and monitoring of children and adolescents with leprosy.
67	Prevention, screening of respiratory symptoms, diagnosis, treatment, follow-up, and investigation of contacts of children and adolescents diagnosed with tuberculosis.
68	Monitoring children with microcephaly / Zika virus.
69	Prevention, screening, diagnosis, treatment, and monitoring of children and adolescents with syphilis, viral hepatitis, HIV, and other STIs.
70	Prevention, identification, counseling, and treatment concerning tobacco use.
71	Prevention, identification, and counseling regarding alcohol and other drugs' abuse.
72	Prevention, identification, reception, and monitoring of situations of violence against children and adolescents, preferably in intersectoral partnership with social assistance and public security services.
73	Prevention and promotion of the safety of children and adolescents against physical injuries: the safety of pedestrians, passengers of motor vehicles and bicycles, prevention of drowning, burns, falls, firearms accidents, and intoxication.
74	Monitoring of children and adolescents with palliative care needs, offering guidance to relatives/caregivers.
75	Home care for children and adolescents bedridden, unable to move, in some post-death situations, or resistance to treatment.
76	Identification and monitoring of children and adolescents with learning difficulties and problems related to the school context or child labor.
77	Identification and monitoring of children and adolescents with physical or mental disabilities.
78	Identification and management of growth and development problems in childhood and adolescence.
79	Identification and follow-up of children and adolescents in situations of vulnerability (violence, child labor, socio-educational measures, institutional care, homeless people, migrants, and refugees).
80	Meeting self-referred demand with risk assessment.
81	Urgent/emergency care for children and adolescents.
82	Identification and management of the most common problems of newborns and infants: infant colic, regurgitation, and vomiting, intestinal constipation, oral moniliasis, miliaria, diaper dermatitis, impetigo, seborrheic dermatitis, jaundice, navel problems, inguinal hernia and hydrocele, retained testicle, developmental dysplasia of the hip.
83	Identification and management of serious health conditions in children under 2 months: convulsions, lethargy/flaccidity, respiratory effort (subcostal retraction, nasal flapping, apnea), groaning/stridor/wheezing, central cyanosis, intense pallor, abdominal distention, weight <2000g, slow capillary filling (> 2s), pustules or vesicles on the skin, manifestations of bleeding (ecchymosis, petechiae or hemorrhages), purulent discharge from the ear or conjunctiva.
84	Identification and management of the most common childhood problems: asthma, iron deficiency and anemia, intestinal parasites, fever, upper airway infections, overweight in children, acute diarrhea, allergic rhinitis, allergic eczema, urticaria/angioedema, allergy to an insect bite.
85	Assistance to the prevalent adolescence problems: pubertal delay, precocious puberty, acne, scrotal pain (cryptorchidism, testicular torsion, epididymitis, varicocele), pubertal gynecomastia, dysmenorrhea, obesity, vulvovaginitis.
86	Identification, management, and monitoring of adolescents with Systemic Arterial Hypertension, Diabetes Mellitus, or with difficulties in visual acuity.
87	Management of the most prevalent chronic respiratory diseases.
88	Assisting and listening to the teenager in any situation, even unaccompanied, as per the Statute of the Child and Adolescent.
89	Promotion, counseling, and comprehensive care for adolescent sexual and reproductive health: individual and group guidance on contraceptive methods; risk management; offering and dispensing prevention supplies and rapid tests.
90	Identification, monitoring, and comprehensive care for pregnant adolescents.
91	Identification, monitoring, and management of children and adolescents in psychological distress, including suicide prevention actions with adolescents.
92	Offer of Integrative and Complementary Practices in the comprehensive care of Children and Adolescents.
93	Identifying and monitoring children and adolescents enrolled in the Bolsa Família (Family Grant) Program or other social assistance or social benefits programs.
	Primary health care procedures
94	Approach and treatment of the person with foot alterations due to neuropathic diseases, such as Diabetes Mellitus (DM) and leprosy.
95	Intradermal, intramuscular, nasal, ocular, oral, parenteral, rectal, subcutaneous, and topical administration of drugs.
96	Blood Pressure measurement and monitoring.
97	Application of Trichloroacetic Acid to a patient without indication for a referral - chemical cauterization of small skin lesions (condyloma, warts).
98	Delivery assistance in urgent/emergency cases, when there is no possibility of timely removal to more appropriate services.
99	Biopsy/puncture of superficial skin tumors with sending of material for anatomopathological analysis.
100	Active search for absentee and contact persons/partnerships of people with communicable diseases.
101	Bladder catheterization (relief and delay).
102	Nail surgery (canthoplasty).
103	Collection of tests (urine, feces, blood, and sputum).
104	Collection of material for the uterine cervical cytopathology.
105	Provision of temporary immobilization (bandages).
106	Stoma care (digestive, urinary, and tracheal).
107	Simple dressings or dressings with exclusive coverings.
108	Autolytic, enzymatic or mechanical debridement, and pressure or ulceration lesion dressings.
109	Abscess drainage.
110	Drainage of a subungual hematoma.
111	Esthesiometry (sensitivity test).
112	Callous excision.
113	Excision of cysts, lipomas, and nevi.
114	Fundoscopy.
115	Immunization / Administration of vaccines.
116	Inhalation with spacer and nebulometer.
117	Infiltration of substances in the synovial cavity (joint, tendon sheath).
118	IUD insertion and removal.
119	Diagnostic maneuvers and otolithic replacement for managing benign paroxysmal positional vertigo (Dix-Hallpike and Epley).
120	The offer of Integrative and Complementary Practices (auriculotherapy/acupuncture / dry needling/trigger point anesthetic infiltration).
121	Breast milking, considering, whenever necessary, the integration with the Human Milk Banks Network.
122	Oxygen therapy.
123	Conducting an intradermal reaction with purified protein derivative (PPD).
124	Conducting the Loop Test to assess people with suspected dengue disease.
125	Removing earwax from the external auditory canal (ear lavage).
126	Removing molluscum contagiosum.
127	Manual removal of fecaloma.
128	Non-surgical removal of worms and parasites.
129	Withdrawal of stitches.
130	Removal/removal of the foreign body: splinters of wood and metal, glass, subcutaneous foreign body, nail injury, removal of a hook, ring, ocular foreign body, in the auditory cavity, nasal, vaginal foreign body, anal, as long as without perforation.
131	Nasogastric tube.
132	Sutures of superficial skin lesions.
133	Epistaxis tamponade.
134	Oral rehydration therapy.
135	KOH test (positive amine test or whiff test).
136	Rapid test for pregnancy.
137	Rapid test for Hepatitis B.
138	Rapid test for Hepatitis C.
139	Rapid HIV test.
140	Rapid test for syphilis.
141	Wound care.
142	Treatment of furunculoid myiasis.
143	Treatment/care of people with burns (except major burns).
144	Use of family approach and guidance tools: genogram, family APGAR, family life cycle assessment, ECOMAP, Brazilian Food Insecurity Scale (EBIA), FIRO and PRACTICE models, identification of family dynamics, and structure, the inclusion of families in the treatment of complex conditions and food surveys.
145	Use of community approach and guidance tools: spaces for community approach in the health unit or other point in the community, groups, holding workshops, preparation of educational/informational materials, territorialization (knowing all the support points of the community, be it health) or not), community therapy and use of data to carry out epidemiological surveillance.
146	Use of reference and counter-reference as tools for sharing care with other services in the care network, as well as the services of the Telessaúde Brasil System.
147	Verification of vital signs (temperature, heart rate, respiratory rate, blood pressure).
	Oral health-related attention and care - dentistry
	Oral Health Promotion and Prevention Procedures
148	Topical application of fluoride gel collective action.
149	Supervised tooth brushing collective action.
150	Topical application of fluoride (individual per session).
151	Dental care for pregnant women.
152	Educational activity/Group orientation in primary care.
153	Visit/Home care.
154	Evidence of plaque.
155	Oral examination for epidemiological purposes.
156	Oral hygiene guidance.
157	Guidance on cleaning dentures.
	Clinical Procedures
158	Access to dental pulp and medication (per tooth).
159	Adaptation of dental prosthesis.
160	Cariostatic application.
161	Sealant application (per tooth).
162	Emergency dental care at PHC.
163	Mouth soft tissue biopsy.
	Oral Health Promotion and Prevention Procedures
164	Pulp capping.
165	Dental Prosthesis Cementation.
166	Fabrication, installation, and adjustment of the muscle relaxant plate.
167	Teeth containment by splinting (dental immobilization).
168	Temporary crown.
169	Delay dressing with or without biomechanical preparation.
170	Periapical curettage.
171	Diagnosis of Temporomandibular Joint Disorder (TMJ).
172	Abscess drainage from the mouth and attachments.
173	Excision and suture of mouth lesion.
174	Excision of injury or suture of injury to the skin, attachments, and mucous membranes (mouth and attachments).
175	Excision of ranulas or salivary retention phenomenon.
176	Extraction of deciduous teeth.
177	Permanent tooth extraction.
178	Multiple extractions with alveoloplasty.
179	Frenectomy.
180	Gingivectomy.
181	Dental prosthesis installation.
182	Dentogingival molding for dental prosthesis construction.
183	An offer of Integrative and Complementary Practices in Oral Health (auriculotherapy, acupuncture, dry needling, trigger point anesthetic infiltration).
184	First programmatic dental consultation.
185	Prophylaxis and plaque removal.
186	Dental pulpotomy.
187	Interproximal radiography (bite wing)
188	Peri-apical radiography.
189	Corono-root scraping by sextant.
190	Subgingival scraping and straightening by sextant.
191	Supragingival scraping, smoothing, and polishing by sextant.
192	Performing an aesthetic procedure in a felt urgency (e.g., need for work).
193	Refilling and repair of dental prosthesis.
194	Dental replantation (per tooth).
195	Restoration of a posterior deciduous tooth.
196	Restoration of deciduous teeth.
197	Restoration of the permanent anterior tooth.
198	Restoration of the permanent posterior tooth.
199	Removal of points of necessary surgeries of skin/attachment and mucous membranes (mouth and attachments).
200	Temporary sealing of dental cavity.
201	Surgical treatment of oral-dental hemorrhage.
202	Treatment of alveolitis.
203	Treatment of Acute Necrotizing Ulcerative Gingivitis (ANUG).
204	Treatment of oral mucosa lesions.
205	Treatment of facial neuralgia.
206	Treatment of pericoronitis.
207	Endodontic treatment of deciduous teeth.
208	Endodontic treatment of permanent anterior tooth.
209	Initial treatment of the traumatized tooth.
210	Atraumatic Restorative Treatment (ART).

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[1] Collaborations

CRH Cunha worked on the design, elaboration, methodology, analysis of results, and the final drafting. E Harzheim worked on the design and final drafting. OL Medeiros worked on the design, methodology, analysis of results, and the final drafting. OP D’Avila worked on the design, analysis of results, and final drafting. W Lucas, LA Faller and C Martins worked on the final essay.