Strategy implementation of hospital and primary care attention services in the healthcare attention network of the M'Boi Mirim region, in Sao Paulo City

Abstract

This research project has the purpose to promote and to evaluate intervention based on capacitation in clinical management focused on diseases that are part of the Brazilian list of ambulatory care sensitive conditions (ACSC). It will be delivered to health professionals who are based in the Hospital Municipal Dr. Moysés Deutsch - M'Boi Mirim (HMBM) and the Family Health Strategy teams spread out to 17 Primary care Units (PCU), in the southern zone of São Paulo City. Also, it will evaluate the use of the communication tools that will be made available to the HMBM and PCU teams: Discharge Summary and two public communication platforms by internet (http://status.net) and cell phones (http://ushahidi.com) that afford the continuity and integrality to the patients who are followed by both health services. Quasi-experimental design with historical Controls study of adult patients who will be hospitalized by ACSC and will be followed by 1 year after the hospital discharge. Data collection will be performed at the both hospital and PCU patients health records including social and environmental characterization, treatment plan adherence, disease monitoring and access to the health services. Data analisys will evaluate as outcomes the hospital readmissions of the followed patients, the use of the communication tools by the health providers, demographic, social and environmental variables, and hospitalization rates, patients time of hospitalization and mortality rates related to the patients of the PCU territories. (AU)