Bakgrund: Lagen om samverkan vid utskrivning från sluten hälso- och sjukvård trädde i kraft 1 januari 2018 med syftet att skapa en trygg, säker och smidig övergång från slutenvård till öppen vård och omsorg. I flera regioner har därför en vårdsamordnarfunktion införts i primärvården. I den region i sydöstra Sverige som författarna valt att studera ska vårdsamordnare, som ofta är en distriktssköterska, med ett personcentrerat förhållningssätt finnas till stöd för de allra mest sjuka, äldre och personer med samordningsbehov. Syfte: Syftet med studien är att beskriva distriktssköterskors erfarenheter av rollen som vårdsamordnare på hälsocentral. Metod: Kvalitativ metod med induktiv ansats användes i studien. Datainsamlingen utfördes genom semistrukturerade intervjuer med nio distriktssköterskor med rollen som vårdsamordnare på hälsocentral i en region i sydöstra Sverige. Data analyserades med en kvalitativ manifest innehållsanalys enligt Graneheim och Lundman. Resultat: I resultatet framkom fyra kategorier och tolv subkategorier. I vårdsamordnarens personliga förutsättningar framkommer betydelsen av yrkeserfarenhet, formell kompetens och att vara bekväm i rollen. Till organisatoriska förutsättningar hörde betydelsen av tid, styrning och personalresurser. Vårdsamordning innebar att arbeta personcentrerat med patienten i fokus där patientkännedom var en fördel. Samverkan var betydelsefullt där kommunikationen hade en central roll. Vårdsamordnaren samverkade internt på hälsocentralen men var även länken mellan andra aktörer. Slutsats: Rollen som vårdsamordnare är mångfacetterad, omfattande och tidskrävande. Förutsättningar och arbetssätt skiljer sig åt. Vårdsamordnarens arbete påverkas av personalresurser och andra aktörers förutsättningar. Fungerande samverkan är en förutsättning för vårdsamordning med patientens behov som utgångspunkt. / Background: The Law on Collaboration in the discharge from healthcare entered into force 2018 with the aim of creating a safe, secure and smooth transition from inpatient care to outpatient care. In several regions a care coordination function has been introduced into primary health care. In the Swedish region the authors have studied, care coordinators, who are often district nurses, with a person-centered approach must be there to support the sickest, elderly and people with coordination needs. Aim: To describe the district nurses experience of the role as care coordinator in a healthcare center. Method: Qualitative method with inductive approach was used. The data collection was conducted with semi-structured interviews with nine district nurses with the role of care coordinator in a healthcare center in a region in Sweden. The data was analyzed by qualitative manifest content analysis according to Graneheim and Lundman. Results: The results revealed four categories and twelve subcategories. In the care coordinators’s personal conditions, the importance of professional experience, competence and being comfortable in the role emerges. Organizational prerequisites included the importance of time, management and personnel resources. Care coordination meant working in a person-centered way with the patient in focus, where patient knowledge was an advantage. Collaboration was significant where communication played a central role. The care coordinator collaborated internally and externally. Conclusion: The role of care coordinator is multifaceted, comprehensive and time-consuming. Prerequisites and working methods differ. Functioning collaboration is the prerequisite for care coordination with the patient’s needs as a starting point.

Ineffectively managed chronic diseases such as diabetes mellitus (DM) increase overall health care expenditures and negatively affects health outcomes such as exacerbations, functional decline, disability, and death. The purpose of this systematic review (SR) was to review the DM outcomes reported by patient-centered medical homes (PCMHs). The goal was to determine how care coordination and evidence-based clinical management impacted financial and health outcomes. The SR followed the Cochrane protocol and complied with the PRISMA evidence-based minimum set for reporting. Overall, DM management in the PCMH demonstrated statistically significant completion rates for essential screenings and preventive care, including HgA1c (p = 0.0013), lipid management (p

abstract: Clinicians confront formidable challenges with information management and coordination activities. When not properly integrated into clinical workflow, technologies can further burden clinicians’ cognitive resources, which is associated with medical errors and risks to patient safety. An understanding of workflow is necessary to redesign information technologies (IT) that better support clinical processes. This is particularly important in surgical care, which is among the most clinical and resource intensive settings in healthcare, and is associated with a high rate of adverse events. There are a growing number of tools to study workflow; however, few produce the kinds of in-depth analyses needed to understand health IT-mediated workflow. The goals of this research are to: (1) investigate and model workflow and communication processes across technologies and care team members in post-operative hospital care; (2) introduce a mixed-method framework, and (3) demonstrate the framework by examining two health IT-mediated tasks. This research draws on distributed cognition and cognitive engineering theories to develop a micro-analytic strategy in which workflow is broken down into constituent people, artifacts, information, and the interactions between them. It models the interactions that enable information flow across people and artifacts, and identifies dependencies between them. This research found that clinicians manage information in particular ways to facilitate planned and emergent decision-making and coordination processes. Barriers to information flow include frequent information transfers, clinical reasoning absent in documents, conflicting and redundant data across documents and applications, and that clinicians are burdened as information managers. This research also shows there is enormous variation in how clinicians interact with electronic health records (EHRs) to complete routine tasks. Variation is best evidenced by patterns that occur for only one patient case and patterns that contain repeated events. Variation is associated with the users’ experience (EHR and clinical), patient case complexity, and a lack of cognitive support provided by the system to help the user find and synthesize information. The methodology is used to assess how health IT can be improved to better support clinicians’ information management and coordination processes (e.g., context-sensitive design), and to inform how resources can best be allocated for clinician observation and training. / Dissertation/Thesis / Doctoral Dissertation Biomedical Informatics 2017

Submitted by Luciana Ferreira (lucgeral@gmail.com) on 2017-03-21T14:44:27Z No. of bitstreams: 2 Dissertação - Ligia Vanessa Silva Cruz Duarte - 2016.pdf: 2459884 bytes, checksum: e7bde5098e4ee7a9e268ee02eb4a23cd (MD5) license_rdf: 0 bytes, checksum: d41d8cd98f00b204e9800998ecf8427e (MD5) / Approved for entry into archive by Luciana Ferreira (lucgeral@gmail.com) on 2017-03-21T14:44:52Z (GMT) No. of bitstreams: 2 Dissertação - Ligia Vanessa Silva Cruz Duarte - 2016.pdf: 2459884 bytes, checksum: e7bde5098e4ee7a9e268ee02eb4a23cd (MD5) license_rdf: 0 bytes, checksum: d41d8cd98f00b204e9800998ecf8427e (MD5) / Made available in DSpace on 2017-03-21T14:44:52Z (GMT). No. of bitstreams: 2 Dissertação - Ligia Vanessa Silva Cruz Duarte - 2016.pdf: 2459884 bytes, checksum: e7bde5098e4ee7a9e268ee02eb4a23cd (MD5) license_rdf: 0 bytes, checksum: d41d8cd98f00b204e9800998ecf8427e (MD5) Previous issue date: 2016-12-20 / Fundação de Amparo à Pesquisa do Estado de Goiás - FAPEG / INTRODUCTION: Studies highlight that care management actions would enable improvements in care continuity and integrality, as they would reduce barriers to access to different health services, performing them in a real and appropriate way. In Primary Health Care, it is necessary that chronic conditions be guided by management practices, aiming at integrating care levels, thus facilitating the ordering of flows and counterflows of people, products and information. This fact puts the PHC in a scenario of constant conflicts of responsibilities, to order and reorder health services and to have more synchronized care. OBJECTIVE: To evaluate care management in PHC using the parameters evaluated by PIAQ - PC in Goiás. METHODOLOGY: This is a cross - sectional study that evaluated PIAQ - PC results in Goiás in 2014. Secondary data from PIAQ-PC External Evaluation database from December 2013 to March 2014 were used. RESULTS: The results of this study allow us to state that there is fragility regarding a consistent registry of the territory, use of standardizations for conducts, agenda scheduling, consultations offering, risk classification and definition of well-defined flows of the user in health units system, in Basic Attention in Goiás, making care barriers and harming those who need them. CONCLUSION: The results found may support the managers' reflection on problems identification in coordination, flow and continuity of care and help in planning, programming and evaluation of intervention measures to be adopted by the Secretary of the State of Health of Goiás and the Municipal Health Secretariats, in order to structure Primary Health Care, making it more resolutive and less expensive. / INTRODUÇÃO: Estudos ressaltam que as ações de gestão do cuidado possibilitariam melhorias na continuidade e na integralidade da atenção, na medida em que reduziriam barreiras de acesso aos distintos serviços de saúde, articulando-os em tempo e local oportunos. No âmbito da Atenção Primária à Saúde, faz-se necessário que o cuidado às condições crônicas esteja orientado por práticas de gestão, com vistas a integrar os níveis assistenciais, facilitando assim, o ordenamento de fluxos e contrafluxos de pessoas, produtos e informações. Esse fato coloca a APS em um cenário de constantes conflitos de responsabilidades, para ordenar e reordenar serviços de saúde e garantir cuidados mais sincronizados. OBJETIVO: Avaliar a gestão do cuidado no âmbito da APS utilizando os parâmetros avaliados pelo PMAQ – AB no estado de Goiás. METODOLOGIA: Trata-se de um estudo transversal que avaliou os resultados do PMAQ-AB, em Goiás, em 2014.Foram utilizados dados secundários extraídos do banco de dados da Avaliação Externa do PMAQ-AB, entre dezembro de 2013 e março de 2014. RESULTADOS: Os resultados desse estudo permitem afirmar que existe fragilidade no que se refere a um registro consistente do território, uso de padronizações para condutas, programação da agenda, oferta de consultas, a classificação de risco e a definição de fluxos bem definidos do usuário dentro do sistema nas unidades de saúde, na Atenção Básica do estado de Goiás, gerando barreiras assistenciais e prejudicando aqueles que precisam dos seus serviços. CONCLUSÃO: Os resultados encontrados poderão subsidiar a reflexão dos gestores quanto a identificação de problemas na coordenação, fluxo e continuidade da atenção e auxiliar no planejamento, na programação e na avaliação de medidas de intervenção a serem adotadas pela Secretaria do Estado da Saúde de Goiás e pelas Secretarias Municipais de Saúde, a fim de estruturar a Atenção Primária tornando-a mais resolutiva e menos dispendiosa.

The ageing population of Sweden is expected to increase throughout the future decades. Changing life-style trends and smaller families in the modern society has decreased the population’s access to informal care. This is expected to entail an increase in the services provided by specialized home care. This thesis studies the work performed by nurses within the department of specialized home care (ASIH) in Stockholm County. The nurses represent the majority of all professions active at ASIH in Stockholm County, which puts their work in particular interest for this thesis. The thesis focuses on the ways the nurses’ work procedures may influence continuity of care and patient safety. Continuity of care is an essential component in qualitative care and is characterized by well-executed coordination and minimization of broken patient appointments. A high level of continuity of care consequently entails a high level of patient safety. Descriptions of continuity of care at ASIH in Stockholm County can therefore provide indications on current care quality and areas of improvement. The thesis consists of two parts – a literature review containing international research on continuity within home care and an empirical study containing a retrospective analysis based on the Functional Resonance Analysis Method (FRAM). The empirical study creates an overview of work tasks related to nursing performed at three units of ASIH in Stockholm County. The interdependencies between work tasks are identified and important chain reactions are analyzed. The findings from this thesis indicate that extended training programs for nurses in the initial phase of employment is likely to decrease the number of disruptions in the nurses’ work. Furthermore, well-developed routines could facilitate work task procedures which would decrease the number of delays and disruptions in the nurses’ work. It was found that these findings together with information continuity between all parties involved represent significant factors for attaining continuity of care and patient safety at ASIH in Stockholm County. / Den äldre befolkningen i Sverige förväntas öka under de kommande årtiondena. Det moderna samhället har dessutom medfört förändrade livsstilar och allt mindre familjekonstellationer, vilket har resulterat i en minskad tillgång till anhörigvård. Detta förväntas medföra en ökad efterfrågan av tjänster som tillhandahålls av specialiserad hemsjukvård. Den specialiserade hemsjukvården ansvaras av Avancerad Sjukvård I Hemmet (ASIH) i Stockholms län. Sjuksköterskor utgör den största andelen anställda av de yrken som är verksamma vid ASIH. Denna rapport undersöker sjuksköterskornas arbetsflöden vid tre ASIH-enheter i Stockholms län. Rapporten fokuserar på att undersöka på vilka sätt sjuksköterskornas arbetsprocesser kan påverka vårdens kontinuitet och patientsäkerhet. Vårdkontinuitet är ett centralt begrepp i kvalitativ hemsjukvård och kännetecknas av välkoordinerad vård och lågt antal otillfredsställande patientbesök. God vårdkontinuitet förväntas medföra hög patientsäkerhet. Återgivningar av den nuvarande vårdkontinuiteten på ASIH i Stockholms län tros därför kunna skapa en uppfattning om den nuvarande vårdkvaliteten samt eventuella förbättringsområden. Denna rapport utgörs av två delar – en litteraturstudie som innehåller internationell forskning om vårdkontinuitet i hemsjukvård samt en empirisk studie som innehåller en retrospektiv analys baserad på Functional Resonance Analysis Method (FRAM). Den empiriska studien skapar en översikt över sjuksköterskors huvudsakliga arbetsuppgifter vid de tre undersökta ASIH-enheterna belägna i Stockholms län. Arbetsuppgifternas korrelationer samt ömsesidiga påverkan kartläggs och signifikanta kedjereaktioner analyseras. Resultaten i denna rapport påvisar att utökad undervisning för sjuksköterskor i anställningens inledande skede kan troligen minska antalet störningar i sjuksköterskornas dagliga arbete. Dessutom påvisar resultaten att fler tydliga rutiner skulle kunna underlätta sjuksköterskornas arbetsprocesser, vilket skulle kunna minska antal förseningar och störningar i deras dagliga arbete ytterligare. Dessa fynd i kombination med välfungerande kommunikationer mellan alla berörda parter utgör de huvudsakliga åtgärderna för att erhålla vårdkontinuitet och patientsäkerhet hos ASIH i Stockholms län.

Large numbers of individuals utilize the ER each year for mental health reasons. The health home agency in this study was designed under the Affordable Care Act with the intention of increasing patient self-management thus decreasing high-cost service utilization. The effectiveness of health homes in reducing mental health-related ER visits has remained unexplored. In this study, the relationship between participation in this program and ER utilization was examined, using the theoretical framework of the Health Belief Model. The sample of 128 health home participants with documented mental health conditions was selected using systematic random sampling. A one-way, repeated-measures t-test and a one-way, repeated-measures ANCOVA were used to analyze hospital records for ER visits with a primary or secondary mental health diagnosis. The results indicated that health home participation did not have a statistically significant impact on ER utilization when comparing overall 12-month means or at quarterly anniversary dates when controlling for age, race, and gender. These findings suggested opportunities for improvement in professional practice, identified areas that require further research, and will be used to initiate discussion into the existing and potential value that health homes offer to the mental health clientele being served. Those discussions have the potential to create social change through infrastructure changes that lead to improved service coordination, increased resources for improving access and quality of care, and overall enhancement of outcomes for individuals with mental health conditions.

No description available.

A presente dissertação, inserida na área temática da Saúde Pública de Regulação e Fiscalização em Saúde (categoria SP1.011.127), destacou aspectos relacionados à política nacional de regulação em saúde. Com base na revisão da literatura relacionada com o tema, o estudo teve como objetivo principal apresentar e discutir os desdobramentos da realização de intervenção no sistema de regulação do acesso à assistência às especialidades médicas de um município de 250 mil habitantes no período de 2009 a 2011. Teve também, como objetivo secundário, analisar estratégias de desenvolvimento e operacionalização de protocolos de regulação do acesso à assistência ambulatorial em perspectiva municipal. Como referencial metodológico foi adotado o estudo de caso com abordagem descritiva predominantemente qualitativa. O capítulo de introdução versou sobre o cenário relacionado com a regulação do acesso à assistência e as intervenções aplicadas. Como resultados foram apresentadas as ações desenvolvidas no município no campo de infraestrutura e tecnologia da informação, aperfeiçoamento logístico e de processos, educação permanente e o desenvolvimento de protocolos de regulação do acesso. Na discussão, foram analisados os processos desenvolvidos, escolhas e ferramentas adotadas para o aperfeiçoamento do acesso à atenção ambulatorial, suas características e vulnerabilidades, discutindo-se as potencialidades desta implementação e o impacto no acesso aos serviços de saúde municipal / This dissertation, inserted in the thematic area of Health Care Coordination and Monitoring (SP1.011.127 category), emphasized issues related to national policy health regulation in Brazil. Based on a review of literature related to the topic, the study had, as main objective, present and discuss the unfolding of intervention performed in the medical specialties accessibility settled in a city of 250 000 inhabitants in the period from 2009 to 2011. Also sought, as a secondary objective, examine strategies to develop and manage regulatory access protocols in that city. The methodological framework was a case study with predominantly qualitative descriptive approach. The introductory chapter was about the scenario related to the regulation of access to care and interventions applied. Results presented the actions developed in the field of municipal infrastructure and information technology, logistics and process improvement, Public Health Professional Education and the development of regulatory access protocols. In the discussion were analyzed the processes developed, choices and tools used for the improvement of Health Services Accessibility, their characteristics and vulnerabilities, discussing the potential of this implementation and the impact on local health services

Introdução - No Brasil mais da metade dos nascimentos ocorrem por meio de cesariana. As pacientes atendidas pelos planos e seguros saúde têm maior chance de passar por uma cirurgia. Embora seja um recurso que salva vidas, a cesárea sem indicação clínica acarreta riscos de saúde imediatos e de longo prazo. Objetivo - Analisar a regulação orientada à redução das cesarianas sem indicação clínica expedida pela Agência Nacional de Saúde Suplementar (ANS) através das Resoluções Normativas RN 368/2015, RN 387/2015 e RN 398/2016 da ANS. Esta tese é uma pesquisa qualitativa com base documental e entrevistas com representantes de entidades relevantes para a formulação de políticas de saúde materna e para a regulamentação dos planos e seguros de saúde. Resultados - Questões relacionadas à regulação das profissões, do modelo assistencial e da relação entre os agentes estão presentes nas causas do problema e não são suficientemente atendidas pelas resoluções normativas. Conclusão - A regulação da assistência obstétrica na saúde suplementar exige ação coordenada de agentes, instituições e entidades que atuam no mercado e na regulação dos planos de saúde, estabelecimentos hospitalares e profissões de saúde, de modo a promover o desenvolvimento de um plano de ação integrado / In Brazil, more then a half of childbirths are delivered by cesarean section. Healthcare insurance system\'s patients have a higher chance to experience surgery. Although an important resource to save lives, cesareans without clinical justifications may cause immediate and in long-term health risks. Objective - Analyse ANS obstetric regulation focused on reducing no clinical indicated cesareans as issued in RN 368/2015, RN 387/2015 and RN 398/2016. The present thesis is qualitative research based on documents and maternal health policies stakeholders interviews. Results - Professional rules and standards, the maternal health assistance model and the relationship between obstetric actors and entities are issues related to the problem causes and not efficiently developed and solved by ANS normative resolutions. Conclusion - Obstetric assistance regulation in Brazilian private health insurance and plans demands action by the Health Ministry coordinating all authorities responsible for healthcare plans, hospitals, and professionals in obstetric assistance as a means of developing an integrated solution plan

A presente dissertação, inserida na área temática da Saúde Pública de Regulação e Fiscalização em Saúde (categoria SP1.011.127), destacou aspectos relacionados à política nacional de regulação em saúde. Com base na revisão da literatura relacionada com o tema, o estudo teve como objetivo principal apresentar e discutir os desdobramentos da realização de intervenção no sistema de regulação do acesso à assistência às especialidades médicas de um município de 250 mil habitantes no período de 2009 a 2011. Teve também, como objetivo secundário, analisar estratégias de desenvolvimento e operacionalização de protocolos de regulação do acesso à assistência ambulatorial em perspectiva municipal. Como referencial metodológico foi adotado o estudo de caso com abordagem descritiva predominantemente qualitativa. O capítulo de introdução versou sobre o cenário relacionado com a regulação do acesso à assistência e as intervenções aplicadas. Como resultados foram apresentadas as ações desenvolvidas no município no campo de infraestrutura e tecnologia da informação, aperfeiçoamento logístico e de processos, educação permanente e o desenvolvimento de protocolos de regulação do acesso. Na discussão, foram analisados os processos desenvolvidos, escolhas e ferramentas adotadas para o aperfeiçoamento do acesso à atenção ambulatorial, suas características e vulnerabilidades, discutindo-se as potencialidades desta implementação e o impacto no acesso aos serviços de saúde municipal / This dissertation, inserted in the thematic area of Health Care Coordination and Monitoring (SP1.011.127 category), emphasized issues related to national policy health regulation in Brazil. Based on a review of literature related to the topic, the study had, as main objective, present and discuss the unfolding of intervention performed in the medical specialties accessibility settled in a city of 250 000 inhabitants in the period from 2009 to 2011. Also sought, as a secondary objective, examine strategies to develop and manage regulatory access protocols in that city. The methodological framework was a case study with predominantly qualitative descriptive approach. The introductory chapter was about the scenario related to the regulation of access to care and interventions applied. Results presented the actions developed in the field of municipal infrastructure and information technology, logistics and process improvement, Public Health Professional Education and the development of regulatory access protocols. In the discussion were analyzed the processes developed, choices and tools used for the improvement of Health Services Accessibility, their characteristics and vulnerabilities, discussing the potential of this implementation and the impact on local health services