Chronic conditions and the new demands to Primary Health Care services

Claunara Schilling Mendonça, Silvia Takeda, Rui Flores, Sérgio Sirena, Lena Azeredo de Lima


Introdução: The Serviço de Saúde Comunitária is a primary care service comprising 450 multiprofessional staff and 105,000 inhabitants. Between 2010/2014 the SSC aims to improve the quality of health care to people suffering from chronic conditions (CC), introducing management, practice and health teams educational changes. A total of 11,178 hypertensive and/or diabetic patients are registered.

Objetivos: To present the changes introduced in management, care provided and educational processes and to illustrate the 2 years changes of results related to the quality of health care by means of access and effectiveness of the care.

Metodologia ou descrição da experiência: Multiple methodologies based on the five topics of the chronic conditions care model; participatory management; activities of permanent education - critical peer education. The evaluation of the care has been through a 4 year longitudinal study evaluating process and outcomes indicators, changes in management, assistance, and educational processes.

Resultados: Increase of access (coverage increase - 34% to 64%); disease control increase (60% to 67%); decrease in hospitalisations due to primary care sensitive conditions.

Conclusões ou hipóteses: We are under a change process. The indicators show that we are following the right path. The learning process has been very reach and useful to be to be shared with others primary care services managers and providers.



Chronic conditions. Cronic Conditions Care Model.

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