Organization of the Health System from the perspective of home care professionals

Abstracts

Trata-se de um estudo de caso qualitativo, cujo objetivo foi compreender a organização da rede de atenção à saúde na perspectiva de profissionais que atuam na atenção domiciliar. Para a coleta de dados, foram realizadas entrevistas, com roteiro semiestruturado, com sete profissionais que trabalham na atenção domiciliar. Por meio da análise de conteúdo, foi possível identificar as seguintes categorias empíricas: Percepção dos profissionais da atenção domiciliar sobre seu trabalho no contexto da rede de atenção à saúde; Dificuldades para a articulação do Programa de atenção Domiciliar com os outros serviços da rede; e Oportunidades para a articulação entre os serviços de saúde a partir do Programa de Atenção Domiciliar. Conclui-se que o trabalho desenvolvido no Programa de Atenção Domiciliar possui interface com outros pontos da rede de atenção à saúde, sendo considerado significativo para se efetivar os princípios doutrinários do Sistema Único de Saúde.

Assistência integral à saúde; Integração de sistemas; Serviços de assistência domiciliar

Se trata de un estudio de caso cualitativo con el objetivo de analizar cómo se organiza el sistema de salud desde la perspectiva de los profesionales de atención domiciliaria. La recogida de datos fue realizada en entrevistas semiestructuradas con siete profesionales de atención domiciliaria. El análisis de contenido reveló las siguientes categorías empíricas: Percepción de los profesionales de atención domiciliaria sobre su trabajo en el sistema de atención de la salud; Dificultades para articular el Programa de Atención Domiciliaria a otros servicios del sistema de salud y Oportunidades para articular el Programa de Atención Domiciliaria a otros servicios del sistema de salud. Se concluye que el Programa de Atención Domiciliaria tiene interfaz con otros programas del sistema de atención de la salud y que es sumamente importante para poner en práctica los principios del Sistema Único de Salud.

Atención integral de salud; Integración de sistemas; Servicios de atención de salud a domicilio

ORIGINAL ARTICLE

^INurse, Master's degree student of the Graduate Programme of the Nursing School at the Federal University of Minas Gerais. Belo Horizonte, Minas Gerais (MG), Brazil

^IINurse, PhD in Administration, Adjunct Professor of the Applied Nursing Department. Nursing School. Federal University of Minas Gerais. Belo Horizonte, MG, Brazil

^IIINurse, PhD in Nursing, Adjunct Professor of the Applied Nursing Department. Nursing School. Federal University of Minas Gerais. Belo Horizonte, MG, Brazil

^IVNurse, Doctorate degree student of the Graduate Programme of the Nursing School at the Federal University of Minas Gerais

^VNurse, Master's degree student of the Graduate Programme of the Nursing School at the Federal University of Minas Gerais. Belo Horizonte, MG, Brazil

^VINurse, Master's degree student of the Graduate Programme of the Nursing School at the Federal University of Minas Gerais. Belo Horizonte, MG, Brazil

Author's address

ABSTRACT

The aim of this qualitative case study is to analyze how the health system is organized from the perspective of homecare professionals. Data was collected by means of semi-structured interviews with seven professionals that provide home healthcare services. Content analysis revealed the following empirical categories: Perception of home care professionals in relation to their work and the health system; Difficulties in articulating the Home Care Program with other services of the health system; and, Opportunities to articulate the various health services with the Home Care Program. Results indicate that the work conducted in the Home Care Program significantly interfaces with other health service programs, and is considered important to implement principles of the National Health Service.

Descriptors: Comprehensive health care. Systems integration. Home care services.

INTRODUCTION

Users of the Brazilian National Health System (SUS) must endure daily uncertainties in relation to access to healthcare services. In spite of the diversity of actions proposed to improve the quality of life of the population, we are faced with new healthcare service demands that result from, among other things, the emergence of new pathologies and new therapeutic resources and approaches. In Brazil, the demographic, epidemiologic and nutritional transition has caused an increase in healthcare demands, which is the result of rapid aging of the population together with the triple burden of disease - infectious-parasitic diseases and malnutrition; chronic diseases and external causes⁽¹⁾.

We are thus confronted with a growing number of hospital admissions, overcrowding and shortages of available hospital beds, as well as risk of infection, all of which lead to overloading of the health system. It is important to point out that this scenario triggers the "need to extend the focus of services to treat chronic conditions, while concurrently dealing with acute conditions"⁽²⁾.

The Health System (RAS) has become an important strategy to improve political and institutional operations of the National Health Service (SUS) to ensure users the set of actions and services they need. Furthermore, a RAS allows the provision of continued health services for a given population at the right time and in the right place, with appropriate costs and quality⁽¹⁾.

From this perspective, Home Care (AD) as a "new" modality of health services that substitutes or complements the existing services is characterized as a set of actions for the promotion and protection of health, treatment of diseases and rehabilitation provided at home, in order to ensure continuity of care integrated to the Health System ⁽³⁾.

Home care involves all health care services and represents efforts to change organization of health services in terms of centralizing care for users in locations that are within their domain, considering that it seeks to overcome the healthcare provision model centred around hospital care, although hospitals are obviously essential in specific situations⁽³⁾.

In the case of Emergency Care Units (UPA), home care is one of the components of the Emergency Assistance Network and must be structured in a coordinated manner, and integrated to the Health System ⁽³⁾. Implementation of Home Care Programs (PAD) linked to the UPA is expanding rapidly and represents an alternative to treat patients that are suffering from the deterioration of a clinical medical condition for which hospital admission is indicated but avoidable by means of home care⁽⁴⁾.

The premise of the Home Care Program is not based on replacing hospital admission, but rather the articulation of the Health System. Consequently, professionals that provide home care should be able to implement actions that facilitate monitoring and recovery of the state of health of users that need emergency care, including patients who are in hospital or at home in a high risk situation and unable to seek assistance.

In light of these facts, this study aims to understand the organization of the Health System from the perspective of professionals that provide home care services.

METHODOLOGY

This is a qualititative case study. This approach was selected because qualititative research is based on concrete case studies according to time particularities and location, considering all expressions and activities of individuals in a local context ⁽⁵⁾.

In the Health System of this capital city, home care services in this municipality are divided into different areas⁽⁴⁾. There are Home Care Programs (PAD) and Home Stay Programs (PID) in municipal, state, federal and philanthropic public institutions, and services in several private institutions and health plan operators ⁽⁴⁾. For this study, the scenario consisted of a Home Care Program linked to an Emergency Care Unit (UPA). In this municipality, there are eight Home Care Program units in eight Emergency Care Units, in nine health districts, currently comprising the municipal public home care system. One Health District of this municipality does not have an Emergency Care Unit, so emergency assistance is provided at a municipal hospital, where there is also a home care team.

Consequently, the scenario of this study was a Home Care Program (PAD) of an Emergency Care Unit (UPA) in a capital city of Brazil. The criterion of totality was adopted to select and include subjects, considering that all seven professionals, of different categories, that made up the home care team were interviewed. Of the seven interviewees, three were nurses, two were nursing technicians, one was a social worker and one was a physician.

Data was collected in the month of June, 2011, by means of semi-structured interviews with the following starter questions: "Can you define the Health System? Elaborate on the subject.", "How do you visualize insertion of the Home Care Program in the system?", "What are the activities of a Home Care Program?", "What is and what should be articulation of these activities be in relation to the Emergency Care Unit?", "Why did you choose to work in the Home Care Program?", "What are the main difficulties you face when working in the Home Care Program?", "And the facilities?" and "Did you receive any training to work in the Home Care Program? Which? Was it relevant?".

Interviews were conducted after the participants signed two copies of a consent form, in accordance with Resolution 196/96 of the National Health Council ⁽⁶⁾. Data analysis was based on theme content assessment related to the three chronological stages, namely: pre-analysis, study of material and treatment of results ⁽⁷⁾.

Results were presented using the code "E" to protect the identity of interviewees, placed after the corresponding spoken interview statements and followed by a number that served as reference for the study data base.

This study was approved by the Research Ethics Committee of the municipal Secretariat of Health and the Research Ethics Committee of the University (CAAE Nº 0057.0.410.203-10).

RESULTS AND DISCUSSION

Data analysis led to the following empirical categories: Perception of home care professionals in relation to their work and the Health System; Difficulties in articulating the Home Care Program with other services of the Health System; and Opportunities to articulate the various health services with the Home Care Program.

Perception of home care professionals in relation to their work and the Health System

Results showed that professionals who work in the Home Care Program perceive the Health System as a necessary configuration to ensure full and equal assistance. According to statements of the participants, the Health System is positive and important, and described as a connection point between a series of institutions that support each other:

When we refer to the health system, we already imagine a series of institutions, all connected and helping each other. This system has to work, but prior to that, it must function in a more efficient manner (E3).

The statement of E3 emphasizes the perception of the Health System as a strategy to allow the exchanging of experiences and knowledge between the different assistance levels. The definition of this system includes some concepts such as cooperation and synergy that target common objectives in the healthcare practice ⁽¹⁾.

Implementation, integration, articulation and operation of a Health System requires the overcoming of the current healthcare model in the National Health Service. Consequently, the logic of rigid hierarchical organizations must be replaced with structured systems in a flexible fabric that is open to sharing and interdependencies of objectives, information, commitment and results ⁽¹⁾.

Some statements revealed an understanding of the Health System as being strongly associated with comprehensiveness, considering that healthcare is established in different types of services for users who, in turn, are perceived as biopsychosocial beings:

I think that the health system is to basically assist those who need healthcare in all aspects of health. I do not only separate health in the physical aspect. I think that health is the emotional factor, the social and economic factor, it's all the factors (E4).

Results indicate an understanding of interdependence and complementarity between services that make up the Health System in order to ensure comprehensive assistance. This is acknowledged as "means" and "ends" for the development of a Health System that refers to integration of services. Comprehensiveness alone is possible through acknowledgement of interdependence of actors and organizations, in view of recognition that none of them have full resources and the necessary competencies to solve the health problems of a population ⁽⁸⁾.

One of the study participants (E6) described the Health System is an organization of the health service that has "several arms", which are equally relevant, with functions that are diversified and proportionally distributed to prevent accumulation of roles:

The Health System has several arms, each of which has a role to prevent accumulation and ensure an organized level. So, I think that in a system, and all that the name entitles, we can see this. Everything has its relevance, nothing is more important than anything else. And I think that the Home Care Program is well established in that system. I perceive the system in that way, a structure that is divided into equal levels to provide people with all the help they need (E6).

This statement reinforces the concept of health systems as polyarchical organization of interconnected health services joined by a single mission, common objectives and a cooperative and interdependent action that allow continued and comprehensive healthcare of a given population ⁽¹⁾.

Primary Healthcare (APS) is considered the structuring axis of the Health System ^(1-2). Study participants expressed an understanding of the relationship between the Home Care Program and Primary Healthcare, and other sectors in the configuration of the Health Systems:

[...] I alternate between the health unit and the patient, I alternate between the patient and other health services, and so forth. With other health services and out-of-network services, such as Association {X}. We get lots of donations for patients, from patients of the Association. We can refer these patients so they receive a pass from the town hall, so they can ride the bus for free. We can refer these patients so they can get a dental implant at the orthesis and prostheses service, and we can recovery health of the patient, we can help this patient build self-esteem, as well as the things that are already dictated, from treatment for infection or declining health issues the patient may have (E3).

I don't focus solely on the patient that is registered in the Home Care Program because there can be a family member in need, an elderly person, for example, and we refer them to other locations. I can get a staple food basket at the extended care NGO, I can get diapers for them. Whatever they need most at that moment. And I make that connection in the team, too, I talk about the case and we refer them to other institutions, as in the case of the CRAS {Social Welfare Reference Centre}, the NASF {Family Health Support Unit} and other cases that have to solved, not only with our help (E4).

Findings in this study indicate the need to create intersectoral and interdisciplinary partnerships that provide full and decisive care to users. They also reveal that association of Health Systems with main principles of the National Health Service (SUS) of equity and universality are considered a strategy to offer unrestricted healthcare to the population:

Well, the health system is based on equity, equality that the National Health Service (SUS) dictates and it offers an unrestricted system for the entire population; unrestricted healthcare for everyone (E5).

You have a more global understanding of the patient, you can meet all their needs because you are in the environment in which they live. So, you have more access to the cause of their problems, you have more tools to alter those causes and then you can treat that person. So, I think that that's the great thing about home care (E6).

The Health System, according to the perception of study subjects, is based on the interconnection between health services reinforcing definitions for that organization. However, there must be advancement towards vertical integration of different service levels during the creation of health policies connected to intersectoral work and management to provide assistance to a given population in terms of complementarity and continuity of healthcare services ⁽²⁾.

Difficulties in articulating the Home Care Program with other services of the Health System

Results allowed the identification of disarticulation of the Home Care Program in relation to other assistance levels, which creates the challenge of articulating the program with the Health System.

Participants of this study acknowledged difficulties of both assistance units (Home Care Program and the Health System) in creating collective work strategies. They particularly acknowledge existing infrastructure challenges of the Health System that hinder articulation with the Home Care Program:

For us, today, the main difficulty is to return the patient to the Health Centre. The Centre claims that there are no vehicles for visitations or that the location is too dangerous. I think that today our greatest difficulty is to complete that transfer to the unit, and it's really difficult to restore that connection with the health unit (E2).

[...] there are difficulties we are aware of, like the vehicle, a smaller team, all those issues (E5).

Some impediments are evidently related to articulation of the Health System with the municipal health service and continuity of healthcare in the Health System units is directly related to availability of transport, equipment and professionals ⁽⁴⁾.

Furthermore, statements showed a lack of standardization and regulations to define flow of access and continuity of assistance^(4,9). In this respect, results indicate lack of knowledge on the location and connection of the Home Care Program in the structuring of healthcare services in the municipality:

[...]

The Home Care Program, contrary to common belief, provides secondary assistance, it is connected to the Emergency Care Unit and not a Primary Assistance Unit to provide home care. So, we have the PSF

{Family Health Program }

, and within the functions of the PSF, we have home visitations

[...]

. And the Home Care Program, its insertion is the following, it is a support service of the Emergency Care Unit, and we "un-emergency" the care, we remove the patients once they are stabilized. It's like a home admission, we re-integrate the patient in the list of patients of the PSF. But then we have this problem, because everyone thinks that the Home Care Program is home visits, only for chronic patients. Others cannot re-instate that patient because we have already done some continued work there and they cannot continue the work due to team difficulties (E5).

Lack of knowledge on the Home Care Program and its concept, its function, insertion into health services and on user admission criteria are factors that hinder effective insertion of the program in the Health System. The interviewed professional emphasize that this situation prevents actual consolidation of work in the system:

Insertion of the Home Care Program, my impression is that it is not very well known, yet. People know that the Home Care Program exists, but no one knows how it works and who it's for, which type of patient it's for, and the requisites the patient must have to be included in the Home Care Program. In general, the system does not know about it as it should, even if it's to benefit more from our work (E3).

So, insertion of the Home Care Program is still a little complicated, the role of the Home Care Program is not well defined in relation to the PSF. Not because of the definition itself, but because of the conception people have in relation to the Home Care Program, they still don't understand what it is very well, and its purpose (E5).

Insertion of the Home Care Program in the system is still not appropriate. I think that it is mostly due to lack of information. So, that way, the health unit does not understand what the work of the Home Care Program is about, in the Emergency Care Units, in hospitals, they don't understand the work of the Home Care Program either. So, the Home Care Program is not fully integrated due to lack of knowledge. Because the Home Care Program is like all the others, it has a very specific function, so if people knew how to use it, it would be excellent for the population (E6).

In terms of lack of knowledge of the Home Care Program work process, aspects related to macro-politics, such as organization and management of health services, should be mentioned. The organization principle of decentralization defined and established by the SUS is that states and municipalities have "political, administrative and financial autonomy"⁽¹⁰⁾. The decision-making process is therefore based on needs and priorities at local level.

The "relevance and potential of home care as an alternative of care organization are not fully understood or known" resulting in the need to construct a system based on complementarity and interdependence of the different system levels⁽¹²⁾. Disarticulation between health services hinders "complementarity of actions and comprehensiveness of assistance"⁽¹³⁾.

The statement of E6 reveals the need for integration with hospitals. This occurs due to the difficulties of existing hospital readmission, insufficiency of support and care continuity strategies and problems related to the reference and counter-reference systems ⁽¹⁴⁾.

There is still a need for strategies that allow minimizing or overcoming of difficulties that arise when establishing the Health System and comprehensiveness in healthcare, considering the additional requirement for assistance continuity and accountability. Subsequently, expansion and qualification of communication and information systems is also necessary between primary healthcare, especially, and home care services.

Beyond the need for articulation between professionals, roles of the different services that make up the Health System should be clearly defined⁽¹⁰⁾. In terms of the Home Care Program, given the diversity of possibilities in this assistance modality, its acknowledgement in the system is more complex because the organization of its technological unit depends on its interface with the different services. Therefore, when organized from the logic of home care, there is a tendency for greater proximity with primary care services; and when organized from the standpoint of home stay, there is greater articulation with hospital services.

Articulation of the Home Care Program with the other services is reinforced by one of the principles of the Health System, namely vertical integration that consists of the articulation of several health services responsible for differential and, above all, complementary actions. Only then will resoluteness and quality be possible in the healthcare work process ⁽²⁾. In this respect, the "challenge of the Brazilian public system is to integrate home care with other health services of the system, including family health teams" ⁽¹⁵⁾.

Opportunities to articulate the various health services with the Home Care Program

Data analysis allowed the identification of elements that reveal possibilities of advancement for the Health System based on the Home Care Program, which chiefly include responsible referral of users and permanent health education, as stated below:

Well, the first thing I think will lead to improvements is to provide guidance at primary care level, it would be really good if people knew that the Home Care Program is not intended to replace the home visits of the PSF (E5).

The Home Care Program is inserted in the Emergency Care Unit with the aim of removing the patient with better health conditions from the Emergency Care Unit, for patients that meet the requirements and it maintains this connection with other levels of the system. So, with primary care, we always try to interact, especially because we often need the health unit for some reason, to notify another institution in favour of the patient. We also make that connection when the patient is released, which is responsible referral, and we always try to maintain contact with the health centre. Many times, we need the ACS {Community Health Agent} to take us to the residence because we often have to visit high risk areas [...] many times we have to return with that patient to the Emergency Care Unit or the hospital system if the patient left the hospital or underwent surgery. So, the Home Care Program, it is not isolated, it is inside the system and it always interacts and communicates with all the other parts of the system (E7).

Results show that the work of professionals of the Home Care Program is optimized through articulation with other assistance services, especially the Health System, which, in turn, calls for elimination of non-accountability and punctual articulation, on a case-by-case basis, enabling a new possibility of integrated work with clear definition of roles of each service required for the continuity of care ⁽⁴⁾.

There is an evident fragility in the context of the Health System in terms of knowledge on the professional practice of home care. In this respect, E5 emphasizes that orientation on these practices for the Health System is important to allow articulation between the services.

Furthermore, the statement of E7 highlights the fact that the home care discharge procedure is an important element that requires effective integration between the Home Care Program and the Health System. There is a wide range of special care requirements of users of the National Health Service after they are discharged that are not included in the practice requirements of the primary care nurse, which means that users are left to the care of secondary level nursing services ^(16-17). The absence of primary care after discharge may lead to worsening of the patient's health condition or additional hospital stay, which causes suffering and emotional burden to the user and family members, and also overloads the Health System. This reinforces the importance of joint, complementary and solidary work between the different health services based on the perspective of continued care ⁽¹⁶⁾.

FINAL CONSIDERATION

This study revealed that, from the perspective of health care professionals, the Home Care Program has an interface with the Health System and is considered important to implement the main principles of the National Health Service (SUS). Furthermore, results allowed greater knowledge of the difficulties and opportunities that are inherent to the construction of a work system. These difficulties mainly include lack of knowledge on the role of the Home Care Program, showing the need to overcome fragmented practice in the health care system. The construction and promotion of knowledge in relation to home care that can be implemented by the professionals of the Home Care Program is therefore necessary.

In relation to advancement possibilities of health services, this study revealed the effective articulation of the Home Care Program with the Health System, although improvements are required in the scope of qualification and sharing of information to obtain full system operations.

The objectives of this study were reached, and the adopted methodological approach was considered appropriate. Additional studies on the daily practice of professionals who work in Home Care Programs is required, especially studies related to articulation, communication and interaction between the existing health services.

REFERENCES

• 1 Mendes EV. As redes de atenção à saúde. Rev Méd Minas Gerais. 2008;18(4 Supl 4):S3-11.
• ²
  Ministério da Saúde (BR). Portaria n. 4.279, de 30 de dezembro de 2010: estabelece diretrizes para a organização da Rede de Atenção à Saúde no âmbito do Sistema Único de Saúde (SUS). Brasília(DF): Ministério da Saúde; 2010.
• ³
  Ministério da Saúde (BR). Portaria n. 2527, de 27 de outubro de 2011: redefine a Atenção Domiciliar no âmbito do Sistema Único de Saúde. Brasília(DF): Ministério da Saúde; 2011.
• 4 Silva KL. Sena RR, Seixas CT, Feuerwerker LCM, Merhy EE. Atenção domiciliar como mudança do modelo tecnoassistencial. Rev Saúde Pública. 2010;44(1):166-76.
• 5 Mazzotti AJA. Usos e abusos dos estudos de caso. Cad Pesqui. 2006;36(129):637-51.
• ⁶
  Ministério da Saúde (BR), Conselho Nacional de Saúde, Comissão Nacional de Ética em Pesquisa. Resolução n. 196 de 10 de outubro de 1996: aprova as diretrizes e nor-mas regulamentadoras de pesquisa envolvendo seres humanos. Brasília(DF): Ministério da Saúde; 1996.
• 7 Bardin L. Análise de conteúdo. Lisboa: Edições 70;2009.
• 8 Linard AG, Castro MM, Cruz AKL. Integralidade da assistência na compreensão dos profissionais da Estratégia Saúde da Família. Rev Gaúcha Enferm. 2011;32(3):546-53.
• 9 Sena RR, Seixas CT, Silva KL, Feuerwerker LCM, Merhy EE. Atenção Domiciliar no Âmbito do SUS no Município de Belo Horizonte. Rio de Janeiro: Universidade Federal do Rio de Janeiro; 2007.
• 10 Martins SK. Diretrizes para a organização do atendimento domiciliar à saúde: contribuições da enfermeira [dissertação]. Curitiba(PR): Universidade Federal do Paraná; 2006.
• 11 Carvalho LC, Chagas MS, Pontes AL. A atenção domiciliar no município do Rio de Janeiro. Rio de Janeiro: Universidade Federal do Rio de Janeiro; 2005.
• 12 Feuerwerker L. Atenção domiciliar no município de Londrina. Rio de Janeiro: Universidade Federal do Rio de Janeiro; 2005.
• 13 Silva KL, Sena R, Leite JCA, Seixas CT, Gonçalves AM. Internação domiciliar no SUS. Rev Saúde Pública 2005;39(3):391-7.
• 14 Rabello CAFG, Rodrigues PHA. Saúde da família e cuidados paliativos infantis: ouvindo os familiares de crianças dependentes de tecnologia. Ciênc Saúde Coletiva. 2010;15(2):379-88.
• 15 Mendes EV. Os grandes dilemas do SUS. Salvador: Casa da Qualidade; 2001.
• 16 Castro EAB, Camargo Júnior KR. Por uma etnografia dos cuidados de saúde após a alta hospitalar. Ciênc Saúde Coletiva. 2008;13(Supl 2):2075-88.
• 17 Silva RVGO, Ramos FRS. O trabalho de enfermagem na alta de crianças hospitalizadas: articulação da atenção hospitalar e básica. Rev Gaúcha Enferm. 2011;32(2):309-15.

Organization of the health system from the perspective of home care professionals

Angélica Mônica Andrade^I; Maria José Menezes Brito^II; Kênia Lara Silva^III; Lívia Cozer Montenegro^IV; Beatriz Santana Caçador^V; Letícia Fernanda de Cota Freitas^VI

Publication Dates

• Publication in this collection
  26 July 2013
• Date of issue
  June 2013

History

• Received
  07 Dec 2011
• Accepted
  06 Feb 2013