Construction and validation of a logical model for specialized Rehabilitation Centers

Valentim, Regis de Souza; Dantas, Thaissa Hamana de Macedo; Machado, Flavia Christiane de Azevedo; Araújo, Camilla Medeiros; Silva, Marilene Soares da; Castaneda, Luciana; Dantas, Diego

doi:10.11606/s1518-8787.2021055002976

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Original Article • Rev. Saúde Pública 55 • 2021 • https://doi.org/10.11606/s1518-8787.2021055002976 copy

Construction and validation of a logical model for specialized Rehabilitation Centers

Authorship SCIMAGO INSTITUTIONS RANKINGS

ABSTRACT

OBJECTIVE

To build and validate a logical model for health care in Specialized Rehabilitation Centers (CER) by analyzing the work process and organizational issues of centers in Rio Grande do Norte.

METHODS

This is a methodological study developed in three stages: 1) documentary research of legislation and ordinances concerning the healthcare service and the Disability Care Network (RCPD); 2) focus groups with a Census study of the CER in Rio Grande do Norte to understand and assess the daily activities of the service; and 3) systematization of the information collected and, finally, proposition and validation of the evaluative logical model.

RESULTS

The model encompassed five central categories of the work and organizational process: “demands”, “resources” (inputs, financial and workforce), “processes”, “products and results” and “mission, values and external factors”.

CONCLUSION

The logical model built was suitable for graphical representation of the work process and organizational issues of the SRC. The study showed that the functioning of the services is in line with the regulations. However, there are still organizational gaps that need to be addressed to improve the resolution capacity of the service and the articulation with other points of the network.

Rehabilitation centers, organization & administration; People with disabilities, rehabilitation; Resource Management of the Health Care Team; Evaluation of Processes and Results in Health Care; Human Resources Administration

Domain and definition^a	Main comments
Demands The subjects and their problems.	Disabilities can be acquired throughout life, and every subject is a potential user of Specialized Rehabilitation Centers (CER). The needs of families and caregivers should be included as service demands, which expands the target audience of CER actions.
Resources Resources can be financial, labor or inputs.	Tripartite financing by the medium and high complexity costing Bloc for Medium and High Complexity Funding (MAC). This type of financing can be a major obstacle to the allocation of resources in the recipient service, which is not guaranteed by these administrative proceedings. Incompatibility of the values offered by the Management System of Table of Procedures, Medications, Orthotics and Auxiliary Means of Locomotion, (Sigtap) and the market values. The human resources are the multiprofessional team, composed of different healthcare categories, in addition to the support and administrative teams. The difficulty of professionals to work in an interdisciplinary manner, delivering comprehensive care focused on human functioning is noticeable. This difficulty seems to be due to how the work is formated and to the qualifications of the professionals, since CER are a recent service.
Processes Actions and tools to achieve the expected products and results.	Global assessment, with classification of human functioning through the International Classification of Functioning, Disability and Health – although this classification is a reality in few services. Shared consultations, unique therapeutic project, health education actions, therapeutic groups and qualified hospital discharge. Assistance actions, matrix support, feeding of information systems and articulation with other services.
Products Materialization of the effort expended in the processes.	Providing habilitation and rehabilitation for people with disabilities, helping these subjects to perform their daily functions and activities independently, in addition to ensuring family support capable of ensuring a harmonious coexistence between the person with disabilities and their nuclear family.
Results Repercurssion and medium and long term impact.	Promoting social inclusion of persons with disabilities, whether at school or work environments, improving their quality of life and ensuring social participation and the exercise of citizenship.
External factors Factors that are outside the scope of teams and can interfere with the performance of the service.	Factors that impact positively: the Forum for Management of the Care Network for Persons with Disabilities, a space for consultation and deliberation on the services delivered, which enables the exchange of experiences and mutual help between services, promoting quality care; partnerships between CER and technical and higher education institutions to qualify human resources and allow training workers to experience the service in practice. Factors that impact negatively: inflexibility of the ordinances governing the CER; difficulty with allocation of resources, intended exclusively for covering costs; lack of instruments to assess the quality of services and actions; difficulty in performing counter-referral and referral; manner of authorization of services by types of disability, disregarding the comprehensiveness of care and limiting the individual’s rehabilitation process.

Problems	Causes	Consequences	Coping strategy
Low visibility of people with disabilities.	Social stigma, lack of information about disabilities.	Social exclusion and isolation. Undervaluation of services and disability care (PcD).	Educational actions on the rights of Persons with Disability and the importance of Specialized Rehabilitation Centers (CER).
Difficulty to apply the biopsychosocial model on the overall assessment, when setting therapeutic goals and on qualified hospital discharge.	Communication deficit between workers and between workers and patients/families. Biology-centered practices and fragmented assessment by different workers. Low or no adherence to the International Classification of Functioning, Disability and Health (ICF) or instruments based on it. Resistance of families / caregivers to accept discharge, due to fears regarding the continuity of care in a home environment or continuity of disability welfare payments (BPC). Low capacity of workers to manage care and lack of evaluation of the quality of care.	Fragmentation of care and therapeutic projects based on the biomedical model, with unilateral practices established without dialogue. Difficulty to set therapeutic priorities and allocate professionals to cases. Lack of autonomy of patient and families in to manage care. Low resolution of actions, with patients staying longer than necessary and increased repressed demand.	Periodic meetings between workers and family members to develop a unique therapeutic project. Global assessment based on the ICF, with the presence of the entire team of workers. Articulation with other points of the network for continued care. Construction and revision of protocols to guide health car delivered by the CER. Development of indicators for evaluation and monitoring of the quality of care delivered in CER.
Difficulty to articulate the CER with other services of the disability care network with other care networks and with other sectors.	Little recognition and appreciation of CER within care networks. Communication failure between the CER and other RCPD services and other care networks. Low qualification of health workers and other sectors to deliver care for people with disabilities and promote inclusion. Logistical difficulties such as lack of sanitary transport and compatibility of schedules.	Little or no intersectoral articulation. Discontinuity of care and social inclusion of persons with disabilities. Worsening distance between specialized attention, other points of the network and social participation of persons with disability.	Periodic meetings with the presence of representatives of attention networks and sectors with other levels of technological density. Development of flowcharts to illustrate the relationship between services and protocols for referral.
Inflexibility of ordinances of the Ministry of Health and allocation of resources.	Disregard of local peculiarities and realities. Poor or non-existent communication between the CER and the Ministry of Health. Incompatibility of the values in the SUS table with the actual cost of products / services. Monthly resource for funding. Mismanagement of resources. Joint resources for CER and other services. Bureaucratization when implementing new CER and lack of interest of managers in doing so.	Fragmentation of care by type of disability, causing patients to travel to several points of the network in cases of multiple disabilities or different habilitation needs of the nearest CER. Need to reallocate other resources to meet the financial demands or diversion of CER resources allocated by MAC. Difficulty regarding technological advancement of the service. High demand for the service and assistance delivered not adequate to the reality of the territory.	Publication of studies on CER to problematize the need for changes in normative instruments. Listening to agents involved with CER to develop guidelines applicable to the service and attention to persons with disability. Reconsidering qualifications by type of disability and creating regulatory systems for access to specialized care and therapeutic inputs such as orthoses and prostheses.
Difficulties concerning Information Systems	Use of the information in the systems for transfer of funds. Electronic medical records not unified between primary care and CER. Information systems based on the diagnosis and biological factors of disability, disregarding the influence of context in the production of disabilities.	Information systems do not reflect the quality of services, which end up being evaluated poorly. Fragmentation of the individual’s health information, hindering access to data by rehabilitation teams and Family Health Strategy, which compromises the comprehensiveness of care. Lack of information systems that allow issuing data on functioning, limitation to activities, restriction to participation and contextual factors.	Encouraging an organizational culture that promotes values of cooperation in the service, planning of actions and evaluation of such actions. Expansion of the electronic medical record of citizens in the e-SUS to include information about CER, enabling a general analysis of individuals through their medical records. Use of information systems with ICF-based data.
Difficulties related to the permanence and qualification of workers, adequate physical structure and alternative therapies.	Workers bound to the service by contract. Low affinity of workers with the CER care model. Back-to-back work shifts, with activities in other care delivery places. Insufficient financial resources for continued education of teams.	High turnover of the care teams. Difficulty in establishing and maintaining the professional-patient bond. Team qualifications are out of date. Curative treatment, based on the biomedical model.	Public tenders and performance assessment to encourage the permanence of workers fit for the service. Periodic evaluation of CER to check on issues related to structure, processes and results obtained.

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[1] Correspondence: Diego Dantas Av. Jorn. Aníbal Fernandes, 173, sala 02 50740-560 Recife, PE, Brazil Email: diego.sdantas@ufpe.br