Evaluation of micro-level managementof older person carein primary healthcenters in a health region in the Federal District of Brazil. Belo Horizonte MG Brasil. Primary health centers PHCs should consider the demographic and epidemiological profile of the health region to respond to population aging and structure service delivery around networks based on macro and micro-level management to ensure the provision of comprehensive services. A normative evaluation of micro-level management in four PHCs in a health region in the Federal District of Brazil was conducted to inform the development of recommendations for enhancing the delivery of comprehensive and integrated long-term care for older persons. A management evaluation matrix was used where management stages were classified as advanced, intermediate and incipient.
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Evaluation of micro-level managementof older person carein primary healthcenters in a health region in the Federal District of Brazil. Belo Horizonte MG Brasil. Primary health centers PHCs should consider the demographic and epidemiological profile of the health region to respond to population aging and structure service delivery around networks based on macro and micro-level management to ensure the provision of comprehensive services.
A normative evaluation of micro-level management in four PHCs in a health region in the Federal District of Brazil was conducted to inform the development of recommendations for enhancing the delivery of comprehensive and integrated long-term care for older persons.
A management evaluation matrix was used where management stages were classified as advanced, intermediate and incipient. The findings show that none of the PHCs were at the advanced stage, three were at the intermediate stage, and one at the incipient stage. The lowest scores were obtained for the subdimensions care model which was shown to be predominantly traditional and humanization fragmentation of care. Lack of infrastructure and staff absenteeism were shown to be constraining factors, while effective communication with local administrators was as facilitating factor.
Improvements need to be made in micro-level management to enhance the delivery of comprehensive and timely care to older persons in this health region. Rising life expectancy and health improvements are worldwide phenomena. However, these improvements are marred by gross health inequalities 1. In Brazil, unlike in most developed countries, the speed of population ageing has been particularly fast 2. As people age, they become more susceptible to complex and costly diseases and functional limitations, creating an economic and social burden associated with the treatment 2 , 4.
The specific health needs of older persons should therefore be taken into account when organizing service delivery and determining a care model that ensures coordinated and integrated care that is appropriate to older people 5.
Micro-level management involves the elaboration of individualized care plans, while macro-level management concentrates on the pathways that are necessary to implement these plans, falling on the administrator to coordinate the components of the network to ensure the provision of a comprehensive service 8.
There are various initiatives in Brazil aimed at prioritizing and ensuring the provision of comprehensive care for older persons, such as the National Health Policy for Older Persons PNSI, acronym in Portuguese , designed to promote quality aging 9.
In addition to the PNSI, the National Policy for Primary Care PNAB, acronym in Portuguese enshrines the Family Health Strategy FHS as the key strategy for expanding and consolidating primary care, increasing resolvability, and improving health outcomes, which requires health services to reshape work processes in order to ensure the provision of comprehensive care The effective functioning of PC is crucial for the effective functioning of elderly care given the central role it plays in the coordination of RAS, where primary health centers PHCs , the mainstay of PC, are the point of entry to the health system.
The management of care for older persons should be guided by individualized care plans, which should include guidance on self-care, support for family members and carers, health education actions, and activities to promote socialization and interaction with other resources 14 - In this context, the effective use of micro-level clinical management technologies is vital to enhance the quality of care and ensure positive health outcomes for older people A literature review evaluating the effectiveness of older person care networks concluded that little research has been conducted on public health programs for older persons and that the methodological quality of studies is generally poor.
The study concluded that, when effectively integrated within and among the different levels and sites of care within the care network, such as hospitals, home care, and social support services, to ensure long-term care based on care plans, primary healthcare is effective in reducing hospitalizations, saves resources, and is more advantageous for patients and their families 5.
It also highlighted that few studies have assessed the organization of work processes focused on this group and that evaluation instruments tend to be general, encompassing the full scope of primary care services rather than those directed specifically at older persons. The author suggests that further evaluations should be conducted in different regions across the country to improve the management of care and promote the adoption of appropriate care technologies, thus strengthening PC for older persons In view of the above, it is important to evaluate micro-level management in PHCs to provide an insight into care provision in these facilities and whether they promote the delivery of comprehensive services and timely access to quality primary care for older populations 5.
A cross-sectional normative evaluation was conducted. A cross-sectional research design was chosen because it is particularly useful for gaining insight into the particularities of a situation to inform future interventions The PHCs were selected using convenience sampling based on the following inclusion criteria: population covered by the PHC has a high proportion of older persons and PHCs whose FHS have been operating for the longest period of time A management evaluation framework 24 subdivided into dimensions, sub-dimensions, and criteria was used to evaluate the use of micro-level management tools by PHC administrators Chart 1.
The maximum total score for the items in the framework was The dimensions that make up the framework were taken from Ministerial Order 4. This classification is summarized in Chart 2. The population of older people in Brazil is 20,,, which corresponds to In the Center-West Region, 8. The Federal District follows the national trend, witnessing an increase in the elderly population and elevated rates of morbidity and mortality due to chronic degenerative diseases 28 , Furthermore, life expectancy at birth of men and women is projected to rise from The Federal District is made up of 31 RAs.
Currently, The literacy rate is 3. The majority of older persons are originally from the Northeast Region The proportion of retired older adults is Management practices provide a unique opportunity to introduce change in services, remodel work processes, and expand the provision of quality care However, health services are complex organizations that, for the most part, are structured according to a pyramidal logic and characterized by hierarchical actions where different types of technology coexist Micro-level management tools, such as health condition management, case management, clinical audits, and waiting lists, are part of clinical management and are a prerequisite for the effective functioning of healthcare networks.
As a soft technology and strategy for the management of health organizations, clinical management can therefore serve as the basis for reshaping health services 35 and dispenses with dialogic relationship in older person care by understanding the cultural, social, economic, historical, and environmental dimensions of care However, the framework analysis shows that one year after the introduction of the legislation regulating the organization of PC in the Federal District, the management tools were either not being used or administrators were unaware of them, as shown in Graph 1.
The results show that none of the PHCs are at the advanced stage in the use of micro-level management tools, one is at the intermediate stage, and two are at the incipient stage. Given the general lack of effective communication between patients, health staff, and administrators, health service provision in Brazil in the past has tended to be fragmented and mechanical, with disjointed coordination of care and insufficient professional accountability In addition to lack of accountability, scarce specialized human resources and insufficient training also hinders the establishment of bonds between patients and health professionals and treatment adherence Despite the fact that other evaluations using the same dimensions, subdimensions, scoring, and criteria used by the present study were not identified and that a cross-sectional design was adopted limited to four PHCs in a single health region, thus hampering generalizations, the findings of the present study are in line with the conclusions of other authors 39 , The findings also showed that the domains that obtained the best scores were those in which recommendations from internal evaluations were implemented, reinforcing the need to develop an evaluation culturethat extends beyond the realm of disease With regard to the subdimensions, three were at the advanced stage, three at the intermediate stage, and two at the incipient stage.
Although comprehensiveness of care and coordination of care were present in all PHCs, the findings show that the PHCs do not always know when patients referred to higher levels of care have been referred back, thus compromising patient follow-up. A study that analyzed the implementation of integrated health service networks and PC coordination strategies in Chile suggested that noncomputerized referral and back referral forms are weak instruments, showing that in the majority of cases PHCs are informed of back referral by the patients themselves or family members These subdimensions are particularly important in situations of family violence, when coordination with social services is vital, demonstrating the need for improvements in this sense.
Intersectorality creates opportunities to embrace the broader concept of health and supports health promotion, a key component of theFHS Given the wide variety of care needs of older populations, PC needs to extend beyond health and social assistance to yield gains in resolvability and effectively address problems.
This requires a new management logic that uses an interdisciplinary approach and shares roles and responsibilities across different areas A study that examined the quality of care from the perspective of older persons in the State of Rio Grande do Norte using the primary care assessment tool PCATool-Brasil showed barriers to accessibility, the need to extend PHC opening hours, and the importance of stepping up actions to promote more comprehensive of care, such as better self-care guidance, social support for older persons and carers, and practices related to nutrition and physical activity Stratification of risk was observed in only one PHC, which hampers understanding of the risk profile of the population, team action planning, and adequate coordination of care.
Clinical management should involve the management of collective and environmental risks through the identification of health problems and the determinants of health in a specific population in order to develop effective measures to improve the quality of healthcare 6.
The scores for these subdimensions were influenced by the following factors: lack of infrastructure including vehicles, insufficient consulting rooms, and lack of medical supplies, medications, and equipment ; FHS staff absenteeism regardless of occupation ; lack of community health agents and family health support center staff; and staff resistance to the proposed care model. Similar results were found by a normative evaluation of the implementation of the FHS in Brazil conducted by the Primary Care Department between and The study found shortfalls in nursing consulting rooms and amounts of medical supplies and equipment and medicines below the required levels, thus hampering primary care provision.
The findings also showed that health professionals, particularly doctors and dentists, did not fulfill the total number of contracted hours, showing lack of adherence to the proposed care model In the PHCs studied, waiting lists are used mainly to regulate referrals to higher levels of care. However, the use of these lists is not transparent because patients need to go the PHC personally to find out their status on the list, leading to unnecessary trips to the health center, especially among older persons.
The findings show that the waiting lists in the PHCs only cover oral health services and that patients can wait up to three years to be treated. For other types of appointments, waiting times average approximately 60 days.
Similarly, a study conducted in Chile showed that, despite the use of care coordination tools such as digital patient records and protocols, care is fragmented and waiting lists are long The provision of long-term care, one of the principles of PC, requires continuous personalized care, including the strengthening of bonds between patients and health professionals and active surveillance, to reduce the risk of health problems However, studies have shown that without adequate human resources, particularly community health agents, and the elaboration of individualized treatment plans, services are unable to meet the diverse needs of older people The findings show that advances have been made on the theoretical and methodological front in the Federal District, pointing to new pathways and presenting different combinations of technologies to promote healthy and active ageing.
Despite the advances made, it is still necessary to overcome vertical management models, improve the training of health professionals to promote a humanistic approach to care and management, break down the barriers of the fragmentation and mechanicalization of care and production line delivery, and consider the subjectivities that envelop health work processes.
As in the rest of Brazil, the Federal District has witnessed significant changes in its demographic profile, resulting in the need to tailor PC to promote quality of life in old age. The findings show that, despite difficulties related to infrastructure and human resources, access to long-term healthcare among older populations has improved, which is likely to increase patient satisfaction and improve clinical outcomes in the long-term.
However, current FHS teams need to be better equipped and new staff need to be recruited. Veras RP, Oliveira M. Cien Saude Colet ; 23 6 Texto contexto - enferm ; 20 2 Veras RP. Linha de cuidado para o idoso: detalhando o modelo. Gerontol ; 19 6 Saude Publica ; 48 2 Mattos RA. Os sentidos da integralidade. Moraes EN. Geneva: OMS; Distrito Federal.
Regulamenta o art. Cien Saude Colet ; 19 2 Serv Soc Soc ; Mendes EV. Ramos NP. In: Hartz ZMA, organizador. Rio de Janeiro: Fiocruz; Tanaka OY. Companhia de Planejamento do Distrito Federal Codeplan.
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