Singular Therapeutic Project in the management of complex cases: experience report in PEW-Health Interprofessionality

Introduction: The Program Education through Work for Health (PEW-Health) was created in 2008 as a partnership between the Ministries of Health and Education, promoting the teaching-service-management-community integration, providing opportunities for professionals, students, teachers, and service users, in line with the needs of SUS, and having the topic of interprofessionality for its ninth edition (2019-2021). This report aims to share interprofessional learning based on the experience of a singular therapeutic project (STP) for a complex case within the PEW-Health activities of a university in the Midwest region, carried out in a Family Health Unit (FHU) in the municipality of Campo Grande, Mato Grosso do Sul (MS). Experience report: Students from a tutorial group of PEW-Health Interprofessionality participated in this experience, as well as preceptors, professionals from the Extended Nucleus of Family Health and Primary Care (ENFH-PC), and a tutor, who was a teacher in a Medical School. The STP was developed with an elderly patient with polypharmacy and the following chronic conditions: diabetes mellitus (DM), depression (DEP) and systemic arterial hypertension (SAH), monitored during the period from August 2019 to February 2020, prior to the COVID-19 pandemic, in a FHU in Campo Grande-MS, selected by the team due to the complexity of the case. Discussion: Through the STP, the group had the opportunity to evaluate, assist and perform practices to strengthen the patient’s “happiness project”. The STP allows team-patient intersubjectivity, focusing not only on the diseases, but on who they are. The carried-out home visits provided moments of listening for the performance of care in accordance with the needs, perceived and not perceived by the user. In the practice of STP, comprehensive care is provided, focused on the individual, showing the potential in continuing education and interprofessional teamwork, sharing knowledge, improving the sustainability of care and, consequently, qualifying health care, corroborating the results obtained in this study. Conclusion: Participation in the program allowed experiences that were previously absent during undergraduate school, such as contact with different health courses, practice in real SUS scenarios and application of concepts seen only in theory, such as humanized care and a comprehensive view, as well as communication with the team and the patient.


INTRODUCTION
Aiming to consolidate the doctrinal and organizational principles of the Brazilian Unified Health System (SUS, Sistema Único de Saúde), several movements have been carried out by the Ministries of Health and Education, over the years, aiming at integrating care, based on the intersectoriality of the professions since undergraduate school, encouraging the formation of professionals capable of teamwork and collaborative production, promoting interprofessionality, meeting the National Curriculum Guidelines (NCG) for courses in the health area 1-5 . However, the experience of interprofessionality during undergraduate school remains a challenge, considering the incompatibility of the curricula of health courses, the different practice scenarios, and the challenges of the teaching-service-management-community integration in SUS 2,6 .
From this perspective, the Education Program through Work for Health (PEW-Health) emerged in 2008, in partnership with the Ministries of Health and Education, aiming to promote the teaching-service-management-community integration, providing experience opportunities for professionals, students, teachers and service users, in line with the needs of SUS 7 , and having the topic of interprofessionality for its ninth edition (2019-2021), indicating the action plan defined for the implementation of changes in care practices, as established by the Pan-American Health Organization 3,7 .
Interprofessional Education (IPE) takes place when "students from two or more professions learn about each other, with others and between each other to allow an effective collaboration and improve health outcomes" (p. 10) 8 . This format seeks to integrate teaching-service through the participation of SUS workers, teachers, and students from different courses in the health area, together developing activities aimed at comprehensive care, at any level of health care 2,3,5 .
The proposition of the IPE is the transformation of health practices through the promotion of the collaboration between professionals and the learning of effective teamwork, advocating learning together to work together. Therefore, adopting the IPE assumptions aims to change health practices and generate interprofessional work in the context of SUS 9 .
While interprofessionality postulates collaborative interaction regarding the specific knowledge of each area, aiming to improve the quality of services and the type of care 10 , multiprofessionality corroborates the fragmentation of care and the demarcation of knowledges 11 . It is understood, therefore, that interprofessionality converts the production of specific care into comprehensive care, promoting teamwork, integrating different professional centers in a collaborative way, focusing on the health needs of users and the population 11 .
In the context of interprofessionality, the Singular Therapeutic Project (STP), a device of the National Humanization Policy (NHP), emerges as a powerful tool for learning and care in Primary Health Care (PHC), considering the historicity and needs of the patient, becoming a care management tool in the transformation into the comprehensive care model, which aims at the production of autonomy, protagonism and social inclusion of the individual [12][13][14][15] .
The STP is presented as an instrument for organizing care, constructed between the team and the user, considering the individual's singularities and their complexity. Complex cases, frequent in PHC 16 , require complex solutions and reveal the need to consider cross-sectional issues in the production of care, comprising a set of proposals for therapeutic approaches, which require the articulation between different professionals and the use of team meetings to reflect on the case and possible solutions 12,13,17 . Thus, by requiring such articulation and collaborative teamwork, the STP gets closer to the IPE, enabling an effective collaboration between professionals and improvement in the comprehensive health care results 11 . Therefore, this article aims to report the interprofessional Paulo-SP, is 68 years old, divorced, retired, has type II DM, SAH and PED, polypharmacy, non-smoker and non-alcoholic, and is literate. She had three pregnancies, two deliveries and a miscarriage, and has two daughters who live in another state, with whom she has a difficult and conflicted relationship. She reported a close relationship with her sister who lives in a municipality in the countryside. She also has a history of surgery on her left knee. The definition of short, medium, and long-term goals that were negotiated with the user respected the principles proposed for the STP 13,25 . The first goal was to improve the condition of the diabetic foot, through actions such as adequate nail clipping, skin hydration, advice on adequate footwear and kinesiotherapy, aiming at improving peripheral vascularization [26][27][28] .
It was also necessary to address the issue of polypharmacy which, according to Mangin et al. 29 , can be considered real risks to the good health of the elderly and, above all, those with comorbidities. It is noteworthy that complex drug regimens tend to exceed the patient's ability to manage, reducing adherence, especially among the elderly, which we verified in practice with the patient, who was not able to adequately organize, alone, the intake of the different prescribed drugs. Although the group had difficulties in changing the prescription, as the team who cared for the user  (Figures 3 and 4) and creating a form to schedule intakes and alarms at the correct times, we sought to ensure the rational use of medications, while considering issues such as loneliness and social isolation, giving voice to the needs felt by the patient, actions that are as important as the prescription 29 .
Prescription intervention occurred due to reports of inadequacy of use, difficulty understanding the prescription and expired medication. At first, the patient's medication "box" was reorganized ( Figure 3). Another strategy was to contact the FHU to schedule an appointment with the only doctor available in the unit, from another team, in order to update the prescriptions. Subsequently, a table was provided with the names of the drugs and stipulated times. In addition, the students made a box with divisions ( Figure 4) for the patient to store the medications correctly, separating them while using the same colors that were included in the table, in addition to providing the correct disposal of expired drugs. Considering the different medication intake times, the students programmed the patient's cell phone with reminders (alarms) at these times.
Following the logic of building happiness projects 30,31 , dreams of resocialization were rescued, as it was shared with the group that her great desire was to return to the university, since she had not been able to graduate due to payment difficulties. An initial resocialization opportunity was the incentive to participate in physical activity groups promoted by the ENFH-PC at the FHU, allowing the reestablishment of

DISCUSSION
In contrast to conventional care models, which focus on curative, specialized, fragmented and individual care, the ENFH-PC work proposal is to overcome this logic towards the co-responsibility and integrated care management through shared care and therapeutic projects that involve users in PHC, being able to consider the uniqueness of the individuals 35   Regarding the fact that the PEW-Health is a macro-policy that triggers IPE in health education, its potential is perceived.
However, it is a particular policy that needs to be incorporated by educational institutions, in PPCs in the health area, to reverse the uniprofessional, curative and hospital-centric logic that permeates society.