Creation of a care transition network and implementation of Palliative Care in State Health Services integrated to the Unified Health System (SUS)

Abstract

This is an innovative research proposal aimed at creating a health policy based on technical-scientific knowledge involving situational diagnosis, needs assessment, modeling, establishing referral flows and developing horizontal integration at the different levels of health care complexity. The target audience is SUS users with life-threatening chronic illnesses that cannot be modified in their natural course and which, in time, will culminate in death, and who suffer from progressively more challenging symptoms and loss of functionality in order to guarantee quality care, comfort and user satisfaction, adding to quality of life and rationalizing health resources. The focus is on the creation of workflows and processes aimed at the transition of care based on the integration of Palliative Care (PC) modalities into the current care network.There is a pressing need to create and implement guidelines for the organization of a care transition and palliative care network in the Health Care Network (RAS). This proposal is based on Resolution No. 41, of 31 October 2018, on the guidelines for the organization of PC in the SUS in the light of integrated long-term care. The aim is to create a model for implementing the State PC Policy (Law No. 17,292 of October 12, 2020). To this end, a situational diagnosis will be carried out with a survey of needs and the selection of health facilities at all levels for this pilot project, with the development of action plans involving macro/micro processes (resources, flows, work processes, creation of protocols and document models, guaranteeing the availability of medication, training and matrix support for actions) with specific regulations for a horizontal health care network with matrix support by a team specializing in PC. The expected results aim to lay the foundations for the creation of an integrated PC network, adding quality of life to SUS users and rationalizing the use of health resources, including the management of PC beds, making it possible to free up hospital beds for acute care and treatment with the expectation of a cure for eligible cases. Among the risks are difficulties in communicating with the care network already in place and resistance to the necessary changes identified in the project (remedied by continuous monitoring, training and matrix support), difficulties in standardizing medications (remedied by creating or adapting distribution flows), difficulties in adapting or creating a single electronic medical record system in the HCN (remedied by adapting or creating it) and budgetary restrictions that make further expansion of the project unfeasible (remedied by the data and results demonstrated in the research).The researchers (scientific and management) worked together to develop the project and will continue to do so throughout the research. The fundamental role of management is to liaise with the necessary bodies in the São Paulo State Health Department (SES-SP) and the health facilities in the HCN at all stages. From a scientific point of view, promoting the actions needed to implement the integrated horizontal PC network in the HCN for future use in the state of São Paulo and in other regions of Brazil, specific HCN training initiatives and matrix support for actions. The scientific results will generate articles, reports, guides/manuals, among others. (AU)