Do existing mechanisms contribute to improvements in care coordination across levels of care in health services networks? Opinions of the health personnel in Colombia and Brazil

Abstract

BackgroundThe fragmentation of healthcare provision has given rise to a wide range of interventions within organizations to improve coordination across levels of care, primarily in high income countries but also in some middle and low-income countries. The aim is to analyze the use of coordination mechanisms in healthcare networks and its implications for the delivery of health care. This is studied from the perspective of health personnel in two countries with different health systems, Colombia and Brazil.MethodsA qualitative, exploratory and descriptive-interpretative study was conducted, based on a case study of healthcare networks in two municipalities in each country. Individual semi-structured interviews were conducted with a three stage theoretical sample of a) health (112) and administrative (66) professionals of different care levels, and b) managers of providers (42) and insurers (14). A thematic content analysis was conducted, segmented by cases, informant groups and themes.ResultsThe results show that care coordination mechanisms are poorly implemented in general. However, the results are marginally better in certain segments of the Colombian networks analyzed (ambulatory centres with primary and secondary care co-location owned by or tied to the contributory scheme insurers, and public providers of the subsidized scheme); and in the network of the state capital in Brazil. Professionals point to numerous problems in the use of existing mechanisms, such as the insufficient recording of information in referral forms, low frequency and level of participation in shared clinical sessions, low adherence to the few available clinical guidelines and the lack of or inadequate referral of patients by the patient referral centres, particularly in the Brazilian networks. The absence or limited use of care coordination mechanisms leads, according to informants, to the inadequate follow-up of patients, interruptions in care and duplication of tests. Professionals use informal strategies to try to overcome these limitations.ConclusionsThe results indicate not only the limited implementation of mechanisms for coordination across care levels, but also a limited use of existing mechanisms in the healthcare networks analyzed. This has a negative impact on coordination, efficiency and quality of care. Organizational changes are required in the networks and healthcare systems to address these problems.

Conhecimento e uso de mecanismos para articulação clínica entre níveis em duas redes de atenção à saúde de Pernambuco, Brasil

“…A implementação dos mecanismos para articulação entre níveis ainda apresenta deficiências em ambas as redes. Essas apontam para possíveis entraves no desenvolvimento das políticas públicas brasileiras e na presença de falhas na organização das redes em saúde 15,16,17,18 .…”

“…Em outros estudos 17,21,22,25 também foram encontradas divergências, que revelam baixos percentuais de recebimento do formulário de contrarreferência. Esse cenário alerta para a utilização apenas burocrática desses formulários, contrapondo com a sua real finalidade de repassar informações úteis que contribuam com a qualidade da atenção e comunicação entre os profissionais 20,25,27 .…”

Comprensión de la gestión de la política pública de protección integral de la infancia en Chile

“…La comprensión fragmentada del mundo natural, de las interacciones y de los sistemas tiene consecuencias como la ineficiencia, la inefectividad y la desigualdad (28). A este respecto, Schütz señala que las personas, al encontrarse con un problema en su actuar cotidiano, deberían dejar de lado sus tipificaciones y recetas, para establecer otras nuevas formas de acción que permitieran respuestas más apropiadas (28,31,32). Es la responsabilidad intersubjetiva, individual y colectiva, como categoría ética y política implicada en el discurso y la acción, cuya inquietud tiene que ver con la capacidad de respuesta de los actores para hacerse cargo de la acción en las prácticas que buscan la transformación (33).…”

O papel do Núcleo de Apoio à Saúde da Família na coordenação assistencial da Atenção Básica: limites e possibilidades

“…Considering the most used mechanisms for administrative coordination (VARGAS ET AL., 2015), the municipality counts on a center to schedule specialized medical appointments and exams, but with action limited to medical specialties. Sometimes, the professionals of Nasf need to refer patients to medical specialties -such as neurology or endocrinology, for example -and the waiting time is too long.…”

“…The coordination of the clinical management is the guarantee of care in a sequential and complementary way by the different services that make up the levels of attention (VARGAS ET AL., 2011) and is characterized by the subdimensions coherence of attention, accessibility between levels and adequate follow-up of the patient. And administrative coordination includes the mechanisms to guarantee patient access along the care line according to their needs (VARGAS ET AL., 2015). It has the subdimensions existence of mechanisms for administrative coordination; administrative reference of the patient to the appropriate unit; and prior programming of care in the transition between levels.…”