Home Care in Brazil: an exploratory study on the construction process and service use in the Brazilian Health System

Rajão, Fabiana Lima; Martins, Mônica

doi:10.1590/1413-81232020255.34692019

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ARTICLE • Ciênc. saúde coletiva 25 (5) • May 2020 • https://doi.org/10.1590/1413-81232020255.34692019 copy

Home Care in Brazil: an exploratory study on the construction process and service use in the Brazilian Health System

Authorship SCIMAGO INSTITUTIONS RANKINGS

Abstract

Changes in demographic and epidemiological profiles, in Brazil and in the world, have brought the need to adapt the health care model. In this context, Home Care (HC) emerges as an alternative strategy of health care driven by several concerns: dehospitalization, rationalization of the hospital bed use, costs reduction, and the organization of patient-centered care. This study aims to analyze HC in the Brazilian Unified Health System, identifying the modalities of care and inequalities in service use. Thereby a documentary analysis of the legislation and secondary data available on the home care volume of services and procedures explorations were realized. In total, 94,754 home-based hospitalizations occurred in the 2008-2016 period, and 4,008,692 home-based outpatient procedures were carried out in the 2012-2016 period. Outpatient HC was more widespread, while home-based hospitalizations were concentrated in some geographical areas. The regional discrepancy is striking, revealing inequalities in supply, access, and use. Despite the legal framework, the establishment of a specific program, and volume of production, HC does not seem to be yet effectively incorporated as one of the apexes of the Health Care Network.

Key words
Home Care; Information Systems; Geographic Locations; Equal Access to Health Care Services

Concepts
Home Care
Brasil (2006)²²22 Brasil. Ministério da Saúde (MS). Agência Nacional de Vigilância Sanitária (Anvisa). Resolução RDC nº 11, de 26 de janeiro de 2006. Diário Oficial da União; 2006.	A generic term that involves health promotion, prevention, treatment of diseases and rehabilitation actions carried out at home.
Lacerda (2006)¹²12 Lacerda MR, Giacomozzi CM, Oliniski SR, Truppel TC. Atenção à Saúde no Domicílio: modalidades que fundamentam sua prática. Saude Soc 2006; 2(15):88-95.	Home care involves the practice of economic, social, and health policies to reduce the risk of individuals becoming ill; enforcement and planning of health programs; and the implementation of care, preventive, and educational activities. Thus, it ranges from promotion to the recovery of individuals affected by a health problem based on their respective homes.
Word Health Organization (USA, 1999)²³23 World Health Organization (WHO). Home-based and long-term care: home care issues at the approach of the 21th century from a World Health Organization perspective - a literature review. Genebra: WHO; 1999.	For the American system, home care can be understood as "home healthcare", with appropriate and quality health care provided to people in their own homes, with cost-benefit compatible with the lives of individuals, who must maintain their autonomy, independence and better quality of life.
Home-based outpatient care
Brazil (2016)²⁴24 Brasil. Ministério da Saúde (MS). Secretaria de Atenção à Saúde. Departamento de Atenção Hospitalar e de Urgência. Segurança do paciente no domicílio. Brasília: MS; 2016.	Home assistance (or home treatment) is a set of scheduled and continued outpatient activities developed at home.
Wealth Canada (1997)²⁵25 Wealth Canada. Policy and Consultation Branch. National health expenditures in Canada 1975-1996: fact sheets [página na Internet]. Ottawa: Wealth Canada; 1997 [acessado 2006 Jul 7]. Disponível em: http://socialpolicy.ca/cush/m7/healthfact.pdf http://socialpolicy.ca/cush/m7/healthfac...	Provision of a provision of health and social services designed to support patients in their own homes.
Ryu et al. (Korea, 2004)²⁶26 Ryu H, An J, Koabyashi M. Home health nursing care agenda based on health policy in Korea. Nurs Health Sci 2005; 7(2):92-98.	"Home care" based on a perspective of the public health sector, through health actions carried out at home, with the family and the community, aimed at patients with chronic diseases and in need of long periods of treatment, avoiding hospitalization.
Thomé et al. (Sweden, 2003)²⁷27 Thomé B, Dykes AK, Hallberg IR. Home care with regard to definition, care recipients, content and outcome: systematic literature review. J Clin Nurs 2003; 12(6):860-872.	Care provided by health professionals to the patient in their own home, with the ultimate goal of well-being, contributing to the quality of life and the improvement of health condition, in order to replace hospital care.
Home Visit
Ribeiro (2004)²⁸28 Ribeiro CA. Assistência domiciliar: uma 'nova' modalidade de atenção à saúde [página na Internet]. [acessado 2004 Ago 5]. Disponível em: http://www.unimeds.com.br/conteudo/ME01.htm http://www.unimeds.com.br/conteudo/ME01....	The home visit is characterized by the timely contact of health professionals with the populations at risk, the sick, and their families to collect information or provide guidance.
Mazza (2004)²⁹29 Mazza MMPR. A visita domiciliária como instrumento de assistência de saúde [página na Internet]. [acessado 2004 Jun 1]. Disponível em: http://www.fsp.usp.br/MAZZA.htm http://www.fsp.usp.br/MAZZA.htm...	In the home visit, actions of guidance, education, collection of possible health solutions, provision of educational subsidies are developed, so that the individuals can become independent.
Freitas (2000)³⁰30 Freitas AV, Bittencourt CM, Tavares JL. Atuação da enfermagem no serviço de internação domiciliar: relato de experiência. Rev Baiana Enferm 2000; 13(1/2):103-107.	The home visit must comprise systematic actions, which start before the visit and continue after it.
Murashima (Japan, 2002)³¹31 Murashima S, Nagata S, Magilvy JK, Fukui S, Kayama M. Home care nursing in Japan: a challenge for providing good care at home. Public Health Nurs 2002; 19(2):94-103.	Home visit activities carried out by nurses, who, after the first contact with the family, define the care approaches, as well as the guidelines to be passed on to the patient and the family for carrying out activities of daily living. It allows the provision of individualized care to the patients, which can be older adults, patients who need special care and advanced technology, terminal patients, or patients with mental illness.
Home-based hospitalization
Ribeiro (2004)²⁸28 Ribeiro CA. Assistência domiciliar: uma 'nova' modalidade de atenção à saúde [página na Internet]. [acessado 2004 Ago 5]. Disponível em: http://www.unimeds.com.br/conteudo/ME01.htm http://www.unimeds.com.br/conteudo/ME01....	Home-based hospitalization is a continuous activity, providing technology and human resources, equipment, materials, and medicines for patients in more complex states requiring care similar to hospital care.
Lacerda (2000)³²32 Lacerda MR. Tornando-se profissional no contexto domiciliar: vivência do cuidado da enfermeira [tese]. Florianópolis: Universidade Federal de Santa Catarina; 2000.	Home-based hospitalization is the continuous provision of systematic and comprehensive care at home, with supervision and action by a specific, tailored health team, centered on the client's reality and involving the family, which may or may not use equipment and materials.
Nogueira (France, 2000)³³33 Nogueira JM. Enfermos crônicos domiciliares: valorização integral físico-cognitiva e caídas durante 3 anos de seguimento. Atencion Primária 2000; 25(3):16-17.	Home-based hospitalization is a health care alternative in the health sector that consists of an organized model capable of providing care and assistance by doctors and nurses, both in quality and in quantity, to patients at home, who do not require hospital infrastructure, but active surveillance and complete care.

Characteristics^* * Only the variables common to the databases consulted are presented.	Home-based hospitalization		Home-based outpatient Care
	n	%	n	%
Total	95,754	100.00	4,008,612	100.00
Year
2008	4,824	5.0	-	-
2009	6,377	6.7	-	-
2010	11,242	11.7	-	-
2011	15,606	16.3	-	-
2012	12,577	13.1	167,965	4.2
2013	10,181	10.6	622,596	15.5
2014	10,315	10.8	1,318,271	32.9
2015	12,177	12.7	1,706,196	42.6
2016	12,455	13.0	193,584	4.8
Gender
Male	46,779	48.9	1,874,056	46.8
Female	48,975	51.1	2,128,264	53.1
Unknown	-	-	6,292	0.2
Age group
0 - 29 days	194	0.2	41,136	1.0
1 - 4 years	3,915	4.1	43,185	1.1
5 - 9 years	2,140	2.2	37,475	0.9
10 - 19 years	4,121	4.3	119,176	3.0
20 - 29 years	4,558	4.8	183,586	4.6
30 - 39 years	5,147	5.4	211,446	5.3
40 - 49 years	7,477	7.8	257,696	6.4
50 - 59 years	11,590	12.1	424,504	10.6
60 - 69 years	16,001	16.7	641,798	16.0
70 - 79 years	19,615	20.5	896,533	22.4
80 - 89 years	15,947	16.7	837,552	20.9
90 - 99 years	4,693	4.9	250,606	6.3
100 and over	356	0.4	19,496	0.5
Skin color/Ethnicity
White	19,532	20.4	1,588,032	39.6
Black	2,426	2.5	234,324	5.8
Brown	18,009	18.8	1,072,427	26.8
Yellow	1,264	1.3	33,798	0.8
Indigenous	19	0.0	318	0.0
No information	54,504	56.9	1,079,713	26.9
Principal diagnosis (Chapter ICD - 10)
II. Neoplasms	8,939	9.3	218,992	5.5
IV. Endocrine, nutritional and metabolic diseases	7,695	8.0	182,402	4.6
V. Mental and behavioural disorders	-	-	123,736	3.1
VI. Diseases of the nervous system	11,679	12.2	601,248	15.0
IX. Diseases of the circulatory system	27,392	28.6	1,239,149	30.9
X. Diseases of the respiratory system	20,874	21.8	179,329	4.5
XII. Diseases of the skin and subcutaneous tissue	6,243	6.5	206,346	5.1
XIII. Diseases of the musculoskeletal system and connective tissue	-	-	95,151	2.4
XIX. Injury, poisoning and certain other consequences of external causes	11,064	11.6	390,294	9.7
Other	1,868	2.0	358,234	8.9
Invalid or unidentified ICD	-	-	44	0.0
Difference/inconsistency	-	-	413,687	10.3
Outcome
Discharge	30,423	31.8	211,974	5.3
Continuing care	50,872	53.1	3,577,290	89.2
Transfer	2,548	2.7	-	-
Referral to Home-based hospitalization (AD1)	-	-	93,820	2.3
Admission to Urgent Care	-	-	13,028	0.3
Hospital admission			37,741	0.9
Administrative closure	10,340	10.8	-	-
Death	1,571	1.6	68,280	1.7
No information	-	-	6,479	0.2
Brazilian geographic region of residence
North	1,208	1.3	155,930	3.9
Northeast	43,324	45.2	1,042,978	26.0
Southeast	21,591	22.5	2,136,830	53.3
South	12,064	12.6	457,637	11.4
Midwest	17,567	18.3	208,945	5.2
Unknown or abroad	-	-	6,292	0.2

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[1] Collaborations

FL Rajão participated in all stages of development of the study and preparation of this paper, and M Martins participated in the design, data analysis, drafting, and critical review of the document.