Management of care for populations with chronic diseases in a Family Health Unit

experience report

Abstract

Problem: Chronic diseases account for the largest share of deaths in the world, configuring a global public health problem, faced with greater difficulty in developing countries, such as Brazil. In the country, primary health care is the gateway to the health system, where it is expected that a population-based approach to the problem will be carried out, with the responsibility for monitoring subpopulations at risk, such as people with chronic conditions. In this scenario, it is important that monitoring tools are created when surveillance of risk indicators is not possible through electronic medical records. This study aimed to report the experience of qualifying care management for the population with chronic diseases in a family health unit based on monitoring using an electronic spreadsheet. Methods: Experience report of an intervention project in a family health unit with the creation of an electronic spreadsheet of clinical data of users with high blood pressure and/or diabetes mellitus in the coverage area and the promotion of ongoing health education in team meetings. Results: From the spreadsheet, it was possible to identify 360 missing users, 68% of the total number of patients with hypertension and diabetes, 146 of these with high cardiovascular risk and, therefore, an active search was carried out with preferential scheduling by cardiovascular risk stratification and home visits. After the actions, it was possible to reduce the number of absentees by 45% and consolidate continuing education on the unit's agenda. Conclusions: From this experience, it is concluded that monitoring users with chronic conditions allows strategic planning and improvement in organizational care management. It is expected that this intervention can be expanded to other health units and that health education actions can be expanded to the territory, for health promotion and prevention.