Process of implementation of a line of care for overweight and obesity from the perspective of a service specialized in rehabilitation in a municipality in the interior of RN

Abstract

Introduction: Obesity is a serious public health problem, defined as a chronic, multifactorial and recurrent disease that can cause metabolic complications, increasing the risk of cardiovascular diseases, reducing quality and life expectancy. In the quest to guarantee comprehensive care and health promotion through the services that make up the health care networks and continuity of care provided to overweight and obese people, the Ministry of Health (MOH) emphasizes the need to implement the Line of Overweight and Obesity Care (LCSO), in order to organize and improve the patient's agenda regarding promotion, prevention, rehabilitation and treatment actions for the people in question. Objective: To report the experience lived during the LCSO implementation process from the perspective of the multidisciplinary team of a Specialized Rehabilitation Service. Method and development: Descriptive study of the experience report type. The implementation process began in September 2022 and is expected to be completed in September 2023, through the FortaleceRAS project, which is part of the SUS Institutional Development Support Program, together with the Syrian Beneficent Association. The project follows the five steps for implementing the Lines of Care, according to the Ministry of Health, which are: situational analysis, definition of strategic actions, team organization, implementation of improvements, monitoring and adjustments. Results: Data are being collected and described as important elements for the organization of work, generating reflection as a multidisciplinary team on the health-disease situation of the population served. Another important factor is the daily and adaptive confrontation of working conditions that directly influence the assistance provided to the people assisted in this service. To this end, instruments were developed to record reliable data regarding user identification, date of birth, national SUS card, weight, height, BMI, line of care, diagnostic hypothesis, risk classification, type of disability, conduct therapy, reason for discharge and counter-referral, using Excel spreadsheets and minutes book. The first data were collected from August 2022 to February 2023. The implementation process is still taking place and several phases need to be covered, analyzed and also reorganized. In addition, there are several challenges to be overcome, especially when we talk about an effective organization of referral and counter-referral flows. Contributions: However, although the process is ongoing, it is clear that there is an integrated multidisciplinary team, promoting great teamwork, always expanding knowledge for users through actions and training in knowledge production and awareness; specialized services carried out, despite the difficulties; resoluteness of management in the supply of materials for specialized care; service coordination responsive to demands and solidification and greater resolution of demands in view of the needs of overweight and obese people and other users of the SUS.