Table 6 Potentialities and weaknesses of chronic disease care practice
Dimension: Care practice organization | ||
Components | Potentialities | Weaknesses |
Schedule and access organization | - Diversification access strategies | - High number of people with chronic diseases per FHT for follow-up - Monthly quota of specialists insufficient to supply demand of people with NCD |
Interdisciplinary action with FHT and FHSC | - Collaborative practices among professionals in FHT | - Big FHSC turnover with the FHT |
Articulation between assistance levels | - Computerization and integration of communication in the FHS | - Restricted integration with other levels of care |
Action planning and follow-up according to health indicators | - Filter for requesting exams and procedures optimizing resources | - Follow-up not based on indicators |
Dimension: Technical care aspects of health care practices | ||
Components | Potentialities | Weaknesses |
Offering a broad portfolio of health promotion, prevention, and care services | - Provision of several promotional, preventive, and care services to people with chronic diseases - Provision of new care technologies | -Division of labor according to professional category |
Use of care protocols | - Knowledge of care protocols by all professionals | - Professional segmentation in the use of care protocols |
Information exchange and case discussion in the multidisciplinary team | - Team meetings held constantly - Good rapport and sense of responsibility between professionals | - Difficulty in contacting and discussing cases with FHSC professionals |
Bond establishment and reception in care practice | - Recognition of the importance of bonding and receive to improve care practices | - High number of people makes it difficult to bond and receive chronic disease patients |
Presence and use of plans/strategies for periodic follow-up and management | - Use of diversified case management mechanisms | - Reactive follow-up with a focus on severe case management |
Consistent data entering in the EMR | - Large-scale use of the EMR - Possibility of using care indicators to promote improvements in the provision of care | - Poor Internet network quality - Poor EMR configuration and interface for viewing and inserting data - Non-integration of the EMR into the care network |
Dimension: Biopsychosocial approach to care practices | ||
Components | Potentialities | Weaknesses |
Knowledge of the socio-epidemiological profile in the registered area | - Recognition of user vulnerability profile for NCD | - Difficulty in action due to the socioeconomic problems of people with chronic diseases |
Intervention actions on social risks and vulnerabilities in the territory | - Broader professional vision to overcome risks and vulnerabilities | - Difficult intersectoral articulation |
Promotion of autonomy and self-care development | Recognition of the importance and availability of health education activities in different modalities in all FHTs | Not identified |
Presence and role of social support network | - Recognition and establishment of partnerships with actors and social support devices in the territory | Difficult articulation with the family for assistance in providing care |