Table 4 Technical care aspects of chronic disease care practices

Providing a broad portfolio of promotion, prevention, and healthcare services aimed at people with HBP and DM

(NUR 15) “(…) there is blood pressure verification (…) capillary glycemia, we have the glycated hemoglobin device (…) immunization (…) health education groups (…) medical consultation, nursing consultation, consultation with the FHSC team (…),we also have the support of community health workers, home visits

(NUR 3) “(…) for hypertensive patients, we offer two groups (educational) (…), in addition to consultation with the medical professionals and myself (nurse) and care (…), which is when I see the patients referred by her (physician) or (…) I guide the HBPM device. Moreover, we visit (homes) (…). Regarding diabetics, we have a group (educational) in the month that is for insulin-dependent and diabetic patients (…).”

Use of care protocols

(PHY 10) “(…) (I use clinical protocols) of course, (…) the question of when the medication will begin immediately, when it is going to be a diet only, in the case of diabetic patients, when to start insulin or hypoglycemic medication, we use all of this.”

Information exchange and case discussion in the multidisciplinary team

(NUR 11) “(…) there is a direct contact with the community health agent and we often do this, the discussion of cases in team meetings always take place when necessary.”

(PHY 3) “(…) Nurse technicians always point out patients who probably have hypertension or diabetes and who have not yet been diagnosed so that we can keep an eye on them. The health workers point out, direct, speak about patients who are not presenting adherence, so there is good rapport in the team.”

Bond establishment and welcoming in care practice

(PHY 5) “(…) so, I won’t tell you we can listen to the patient calmly, because we can’t, the demand is high, so I try to get most problems the patient is bringing to me, but more time with the patient would be better.”

(NUR 5) “(…) we began visiting (home) these patients (hypertensive and diabetic) and on the visit I schedule the consultation and establish a bond.”

Presence and use of plans/strategies for periodic follow-up and management

(PHY 2) “(…) I try periodic follow-up and case management with severe patients, decompensated patients. I don’t follow-up with others who are compensated.”

(NUR 13) “(…) with all of them (patients) the return is on demand, when they think they need to come they come, the prescription is always renewed, because the obstacle is not distributing the medication.”

Consistent data entering in the EMR

(PHY 4) “(…) the EMR is awful. It is a long chart, redundant, repetitive (…). We have Internet instability in the city and frequent EMR updates from the health ministry. It also has a bad interface, it is not presented first when you are seeing a patient, it already opens in the clinical part, then you do not see previous comorbidities, previous medications, previous clinical history, so its organization is awful

(NUR 11) A difficulty (with EMR) that is unbearable is to enter all exam data, I think a lot of record is lost (for this)