Coordination, integration, and continuity of care: what do we need after 30 years of the Family Health Strategy?

Melo, Eduardo Alves; Silva, André Schimidt da

doi:10.1590/1413-812320253012.16232025

Abstract

The Family Health Strategy (FHS), after thirty years, has shown numerous advances in reorienting the care model, expanding equitable access, and improving population health. However, networked care remains an unresolved issue. This article addresses the challenges and possibilities for care coordination within the FHS, which is the predominant model for structuring Primary Health Care (PHC) in Brazil, considering its role within care networks and regions of the Unified Health System (SUS). Initially, a brief overview of the situation regarding coordination, continuity, and integration of care is presented. In addition to recognizing the internal aspects of coordination within the scope of PHC (also related to access, quality, and availability of care), this article discusses decisive factors for coordination that go beyond PHC, particularly those related to the organization and functioning of specialized care, while still focusing on their connection with structural challenges of SUS. This article also explores certain mechanisms for coordination, integration, and continuity of care between PHC and SC. Finally, it presents technical-political strategy proposals to improve care coordination by the FHS.

Key words:
Primary Health Care; Family Health Strategy; Care coordination; Specialized care

Resumo

A Estratégia Saúde da Família (ESF), após seus trinta anos, apresenta inúmeros avanços na reorientação do modelo assistencial, ampliação do acesso com equidade e na saúde da população. Contudo, o cuidado em rede permanece como questão não resolvida. Este artigo aborda desafios e possibilidades para a coordenação do cuidado na ESF, modo predominante de conformação da atenção primária à saúde (APS) no Brasil, considerando sua posição nas redes de atenção e regiões do Sistema Único de Saúde (SUS). Inicialmente, realizou-se breve caracterização da situação no que tange à coordenação, continuidade e integração de cuidados. Além de reconhecer a face interna da coordenação, no âmbito próprio da APS (relacionando-se também com o acesso, qualidade e ofertas de cuidado), elementos decisivos para a coordenação que extrapolam a APS são tematizados, notadamente aqueles ligados à organização e funcionamento da atenção especializada (AE), sem perder de vista sua relação com desafios estruturais do SUS. Exploram-se também alguns dispositivos de coordenação, integração e continuidade do cuidado entre APS e AE. Por fim, o artigo apresenta proposições de estratégias técnico-políticas para avançar na coordenação do cuidado pela ESF.

Palavras-chave:
Atenção Primária à Saúde; Estratégia Saúde da Família; Coordenação do cuidado; Atenção especializada

Resumen

La Estrategia de Salud de la Familia (ESF), después de treinta años, presenta numerosos avances en la reorientación del modelo asistencial, en la ampliación del acceso con equidad y en la mejora de la salud de la población. Sin embargo, la atención en red sigue siendo una cuestión no resuelta. Este artículo aborda los desafíos y posibilidades para la coordinación de la atención en la ESF, modalidad predominante de organización de la atención primaria de salud (APS) en Brasil, considerando su posición en las redes de atención y en las regiones del Sistema Unificado de Salud (SUS). Inicialmente, se realiza una breve caracterización de la situación en cuanto a la coordinación, continuidad e integración de los cuidados. Además de reconocer la dimensión interna de la coordinación, en el ámbito propio de la APS (relacionada también con el acceso, la calidad y la oferta de cuidados), se abordan elementos decisivos para la coordinación que trascienden la APS, especialmente aquellos vinculados a la organización y funcionamiento de la atención especializada (AE), sin perder de vista su relación con los desafíos estructurales del SUS. También se exploran algunos dispositivos de coordinación, integración y continuidad del cuidado entre la APS y la AE. Finalmente, el artículo presenta propuestas de estrategias técnico-políticas para avanzar en la coordinación de la atención a través de la ESF.

Palabras clave:
Atención Primaria de Salud; Estrategia de Salud de la Familia; Coordinación del cuidado; Atención especializada

Introduction: advances in Brazilian PHC and the persistent challenge of care coordination

Thirty years after the Family Health Strategy (FHS), the reorientation of the care model, based on territoriality; proximity care; multidisciplinary teams; and individual, family, and collective action, has produced numerous advances. The expansion in the number of teams (currently over 51,000)¹ and population coverage has enabled increased access to and use of services (strengthening the first-contact attribute²), reduced infant mortality and adult mortality rates owing to some key conditions sensitive to Primary Health Care (PHC), improved infectious disease control, and a diminishing of health inequalities³. This process has led to the prominence of Brazilian PHC among established international experiences⁴. Moreover, the FHS, along with its federal influence (via an innovative financing strategy) and the municipalization of healthcare, has contributed to the materiality, reach, and visibility of the Unified Health System (SUS) in its implementation process since the 1990s⁵. Over the past decade, the More Doctors (Mais Médicos) Program has fostered renewed visibility, providing an unprecedented number of professionals to PHC in numerous areas throughout the country that have struggled to attract and retain professionals⁶.

While these achievements deserve and require celebration, we believe it is also appropriate to recognize existing limits and obstacles, a fundamental step toward expanding the positive effects of PHC upon people’s lives, its legitimacy, and its broader contribution to SUS. These limits are partly conditioned by the structural challenges that SUS is currently facing, involving its financing, the regionalization process, public-private relations, and the formation of public careers⁷. Add to this the recent history of worsening problems related to living and health conditions in the face of crises and the COVID-19 pandemic, as well as the socio-political setbacks the country has experienced in the last decade.

Given the heterogeneity of SUS (and PHC in particular) experiences across Brazilian municipalities, there are still issues to be addressed in expanding access to health care, such as the number of staff per team, armed violence in metropolitan areas, distance in remote rural areas, limited communication and contact between users and teams, and other organizational barriers (scheduling, operating hours, enrollment mechanisms, among others)⁸^-¹⁰.

Regarding workers, the most notable challenges are the progressive precariousness, outsourcing, and near-absence of careers¹¹ (despite the fact that PHCs are almost exclusively public and state-owned), as well as the still insufficient regulation of professional and specialist training, one of the impacts of which is the insufficient number of physicians with residencies or specializations in Family and Community Medicine, albeit growing¹².

In this context, the focus of this article is care coordination, an essential attribute of PHC, internationally recognized and adopted by the National Primary Care Policy. Coordination was considered in the current situation of the FHS and in connection with other attributes of the PHC, as is the case with the principles of SUS, in which universality, equity, and integrality need to be seen as a tripod with a joint effect and not in isolation, despite the fact that each principle has its own singularity¹³.

Thus, this article addresses challenges and possibilities for care coordination in the FHS, against the backdrop of its place within SUS networks and regions. The debate over the FHS’s position within the healthcare network has renewed its timeliness in the current context, in which the Ministry of Health (MoH) is introducing, for the first time, a new and complex policy, seeking to promote a different organization of specialized care. Through a new financing model, the aim is to directly address one of the population’s main dissatisfactions with SUS: long waiting times for specialized appointments and exams.

It is important to remember that care integration is intertwined with contemporary issues in healthcare systems worldwide, such as their economic aspects, inequalities in access, the search for effective care models, complex and emerging health problems, productive restructuring and digital transformation in healthcare, as well as population aging and the challenges of chronic condition care.

The first section of the article seeks to revisit the concepts of coordination, integration, and continuity, characterize the current situation, and present key elements for considering care coordination through PHC within SUS. Next, the main care coordination, continuity, and integration mechanisms implemented or discussed in Brazil are described and problematized. Finally, a set of technical-political strategies is proposed that, if implemented, would have the potential to impact important critical nodes for care coordination based on the FHS.

Contemplating the coordination, integration, and continuity of care through the FHS: notions, situations, and key elements

Care coordination can be understood as the ability to manage a person’s care, advocate for the user, monitor and manage their care trajectory, and defend their life based on relationships of bonding and accountability¹⁴. However, coordination, integration, and continuity of care are concepts that sometimes overlap and become intertwined, requiring an understanding of their specificities, intersections, and complementarities. For reference purposes only, it is worth remembering that formulations around the notions of care management and clinical governance (or management), respectively Brazilian and Anglo-Saxon, while seeking to bridge the gap between the worlds of management and care, and recognizing distinct actors and spaces that directly or indirectly influence health practices¹⁵, also target, to some extent and despite their differences, elements that relate to this discussion.

Care coordination is often understood as the active and systematic management of actions that comprise a patient’s care, involving two or more participants in this process, including the patient themselves, to ensure the appropriate delivery of care. This process involves coordinating professionals and other resources necessary to implement the planned interventions and is often facilitated through the structured exchange of information among those responsible for different aspects of care¹⁶.

From a broader perspective, integration constitutes a process aimed at creating and maintaining governance among autonomous actors and organizations, with the goal of coordinating their interdependence, facilitating cooperation for the execution of shared care projects. This process recognizes that no single party possesses all the resources and capabilities necessary to effectively address the health problems of a population throughout their distinct life cycles¹⁷.

Recurrently in studies on the subject, integration is analyzed from two dimensions. So-called vertical integration refers to the coordination between different service modalities involved in health care. In the context of health care, this implies the connection among PHC, diagnostic services, specialized outpatient clinics, emergency units, and hospitals, among others, to ensure the continuity of patient care. In turn, horizontal integration involves the organizational alignment among actions, services, and actors within the same care domain, with the goal of providing a more effective response to the demands of users with multiple health conditions and complex care needs¹⁸.

Continuity of care, in turn, refers to the degree to which a series of distinct care events is perceived as a coherent, articulated process, compatible with patients’ clinical needs, as well as their social and personal contexts. The temporal dimension and a person-centered focus, considering their trajectory and uniqueness, are the two key elements of continuity¹⁹. Haggerty et al.¹⁹ enumerate three dimensions of continuity of care: informational continuity, which ensures the appropriate use of patients’ clinical and personal data; managerial continuity, focused on the coordination and integration of therapeutic plans; and relational continuity, based on maintaining bonds between the patient and healthcare professionals¹⁹.

Considering these nuances, distinctions, and complementarities among these terms, this article proposes incorporating integration and continuity into care coordination to more broadly define the desired objective: avoid discontinuity; provide timely, appropriate, qualified, and humane care; and establish spaces and actors with responsibility, legitimacy, and effective conditions for care to be provided throughout the network¹⁵. Although this process occurs in part within the PHC itself or within a single service, the present article focuses on the most critical aspect of coordination in the FHS: the articulation of PHC with different service modalities and agencies. The choice of this approach (among different health services), however, does not ignore the relevance and advances made in Brazil in terms of multidisciplinary teamwork at different points in the system - psychosocial care, SAMU, home care, and the experience of the Family Health Support Centers (Núcleos de Apoio à Saúde da Família - NASF) and FHS. Nor should we forget that comprehensive care often requires coordinated work with other policies (beyond health), including advances in health processes, such as dehospitalization.

In Brazil, it has become something of a “mantra” to say that PHC is the care coordinator and network organizer. This is not a problem in itself, but it could become one if it falls into a normative, idealized, and decontextualized logic²⁰. Indeed, the authors’ empirical experience with services and management in different locations and settings, and especially the publications of existing studies in Brazil (with varying scopes), reveal that care coordination by PHC, when users require specialized care or are cared for in different services, is still more the exception than the rule²¹^-²³. In the international context, care coordination also proves challenging, sometimes with limited capacity to guide flows from PHC, both in relation to access to specialized services and traditional public health actions²⁴.

What is frequently observed in Brazil are uneven levels of responsiveness to user needs²⁵, minimal interaction between professionals from different services²⁶^,²⁷, in a kind of chimera of referral and counter-referral, of a bureaucratic nature and with little adherence among professionals²²; care regulation that is distant from PHC and focused on isolated procedures rather than on access to integrated care²⁸, despite the increasing structuring of spaces and processes for regulating access²⁹; long waiting times for specialized care (with variations depending on the specialty, examination, procedure, or location)³⁰^,³¹; the near absence of clinical information shared electronically between services of different modalities³², despite a significant increase in electronic medical records in PHC²⁹; and additional and even more significant difficulties in accessing specialized care for users from municipalities with smaller populations, even with agreements on referral services between municipalities in certain health regions³³. Furthermore, with some frequency, users pay out of their own pockets for medical consultations and examinations in the private sector, seeking to build their own care itineraries through different strategies³⁴, a process reinforced by the presence of so-called popular private clinics, often exposing users to new problems and fragmentation of care³⁵.

Given this, it is necessary to characterize some of the key elements for coordinating care within PHC, without losing sight of the fact that other dimensions and challenges of PHC also influence its coordination capacity, whether directly or indirectly.

The first key point concerns PHC’s ability to welcome and create bonds with users. This is not something decreed, like a formal assignment, but rather something that is built procedurally - a bond as an affective and trusting relationship, a central element of care, a lightweight technology par excellence. This bond can function as a reference, a safe haven for users, and a point from which the commitment to strive to ensure care and access to what users need is structured. This bond is also related to accountability for cases and their follow-up, whether users are being cared for in PHC or in other services. To this end, facilitated access to PHC is an important first step, and should be followed by the ability of FHS teams to monitor and respond to health demands and needs, as discussed below.

The second aspect, then, concerns the technical quality of professionals and the scope of care practices and offers, essential for addressing and managing different health problems and conditions and for the legitimacy of PHC among users and professionals in specialized services. This concerns the clinical and care capacity of the FHS, necessary for care coordination, expressing the PHC’s problem-solving and management capacity. These elements influence the quality and relevance of demands for exams, treatments, and care in specialized care, helping to avoid referrals and prescriptions without indication, improving referral methods (e.g., prior care, patient preparation, provision of essential information, among others), as well as addressing market interests and the medicalization process that arise and generate demands, even if addressing them extends far beyond PHC.

The third element refers to the coordination between professionals in the care network (conceived by some authors as interprofessional collaboration³⁶), which may or may not be favored by the logic of work organization and the existence of effective mechanisms for interaction (remote and/or in-person).

The fourth aspect concerns the coordination between services and management bodies (also referred to as interorganizational collaboration)³⁶, which depends on the availability and spatial distribution of professionals and specialized services, the relationship between supply and demand for actions and services at the local-regional level, care flows, regional governance, mechanisms for regulating access to medical exams, consultations, and interventions, as well as the logic of organization and operation of specialized care.

Finally, as a fifth aspect, the integration of essential clinical information of users stands out (information shared between services, with attention to proper data protection), to avoid doubts about diagnostic and therapeutic data, repetition or overlapping of procedures, delays in care due to a lack of information, and avoidable displacements, as well as to enable the monitoring of the care process.

The last two elements clearly go beyond the scope of PHC, in addition to addressing technical, organizational, and political dimensions involved in the planning and management of a service network. In this regard, some considerations are necessary. Formal coordination of the network cannot be carried out by PHC (as is often presumed); this falls to managers, with social and employee participation. The organization of the network by PHC, in turn, depends on the scope and functioning of PHC, as well as on the extent to which the management of the various services and the macro-management of SUS in the health regions incorporate and implement this idea in decision-making, such as before (or during) the implementation of a new hospital, or an outpatient or emergency service.

Furthermore, in some specific and less frequent situations, access to specialized care resources does not necessarily have to be granted solely through PHC requests to regulatory centers, such as in specialized rehabilitation after hospital discharge, upon completion of a diagnosis, or in the preoperative cycle. This avoids bureaucratization that compromises continuity of care, but it is essential to ensure the timely availability of information about this process to PHC. Finally, in specific cases, care coordination can be shared between PHC and specialized services, such as mental health intensive care, oncology, and renal therapy. The specific situation must be compared with the ideal of coordination to find the necessary mediations, while simultaneously considering the best interests of each user and the organization of a system that aims to guarantee universal access.

Rather than simply repeating the mantra mentioned at the beginning of this section, it is crucial to question how our PHC is doing in relation to each of these aspects; ask, if change is possible, what the potential and scope of ongoing initiatives and measures are, and how to move forward.

Devices for integration, continuity, and coordination of care in SUS

This section will explore some devices that can advance the coordination, integration, and continuity of care. Chart 1 presents these devices.

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Chart 1
Devices for coordination, integration, and continuity of care.

As can be seen, some devices, such as care pathways, are predominantly organizational in nature, while others are technologically instrumental (such as electronic records). Certain devices are more relational and interprofessional, such as matrix support. In a way, this reveals distinct areas and strategies for coordination, which are not limited to the direct work of healthcare professionals, although they almost always materialize or converge in this space. These are not, however, devices with a new formulation today, but, given their potential and experimentation, they deserve to be revisited to help reflect on the difficulties and possibilities for coordination. In this sense, albeit briefly, some key comments may be in order.

Care pathways would allow users to move through the network in a more planned manner, with clear definitions of the roles of professionals and services, in addition to materializing the notion of a network in specific situations. Although common in experiences in large cities (such as the line of care involving prenatal, childbirth, and postpartum care), implementation at a regional level is still incipient, in addition to having limits inherent to its focal nature.

Matrix support has the potential to contribute to reducing care fragmentation and increasing clinical accountability⁴¹. Although it has gained traction with the implementation of NASF and can be conducted in-person or remotely, matrix support appears to be limited to interactions with multidisciplinary PHC support teams⁴² and Mental Health services⁴³.

Although common in mental health services and some rehabilitation centers, unique therapeutic projects are still relatively under-incorporated in PHC, potentially requiring adaptation or a different design of the system for this setting based on the specific needs of the target audience, types of demands and health needs, and work organization.

Regarding access regulation, some limitations should be observed, such as constraints on certain offers (regulation of scarcity), the focus of regulation on isolated procedures (rather than integrated care), the lack of publicity regarding waiting times, and the coexistence of different waiting lists, under different management/responsibilities, for the same procedure in a given area.

Although successful experiences do exist⁴⁴^,⁴⁵, co-management between services faces political and organizational obstacles to its viability, even in municipalities that manage different types of services.

Advances in electronic health records have been observed in SUS over the last decade, particularly through the e-SUS PHC strategy, which laid the foundation for a new information architecture, promoted integration with some traditional health surveillance systems, and expanded the use of electronic medical records in PHC⁴⁶. However, the current lack of implementation of a public, national strategy and tool for clinical records in specialized outpatient and hospital care, developed to integrate and interact with PHC and healthcare regulatory processes, restricts information sharing between different types of services.

Although not specifically discussed, it is important to note that some of the conditions necessary to implement these mechanisms generally relate to the establishment of regionalized healthcare networks and, in particular, the provision, financing, organization, and operation of specialized care, as well as its dependence on the structural dimensions of SUS. Furthermore, unlike APS, it is important to remember that specialized care in SUS is predominantly private (philanthropic or “pure”/typical) and contracted.

To advance in the coordination, integration, and continuity of care provided by PHC

Considering the limitations and problems identified, the characterization of key points, and the existing mechanisms, we propose here, on a preliminary basis, some strategies that, once adopted, could shift the current scenario of low capacity for PHC care coordination toward more effective coordination. Rather than simply establishing the specific proposals themselves - which are, of course, subject to change and consideration depending on the scenario - the intention is to highlight strategies with the potential to shift the current drivers of coordination and address the critical issues within the key previously mapped aspects.

a) To expand the clinical and care capacity of PHC, among numerous measures (which are certainly not limited to physicians, but necessarily include them), the following should be highlighted:

Financially encourage the expansion of the scope of diagnostic and therapeutic actions in PHC, incorporating digitalization and new technological care arrangements (tele-electrocardiogram, teledermatology, chronic pain care, teleconsultations, laboratory tests, imaging tests, among others).
Define a feasible goal and deadline for the specialization and certification of family physicians and nurses in Brazil, adopting different training strategies and incentives (training pathways, competency certification, expansion of residencies, and devices to encourage their completion, specialist qualification exams, financial incentives linked to training, requirements and appreciation of specialization, among others).

Expanding the scope would have the potential to improve the responsiveness and legitimacy of PHC, as well as reduce referrals and the need for patient travel. This requires investment in technological incorporation and professional qualifications, as well as in the organization of processes and working conditions. Qualification would enhance the technical quality of professionals, align their profile with the nature of PHC, and contribute to professional development and appreciation over time.

b) Regarding the more direct role of the PHC to enable user access to specialized services and resources, the following proposal deserves attention:

Decentralization of some of the prerogatives and functions of access regulation to PHC, using strategies, such as basic training in regulation, quotas parameterized by regions/units with timely monitoring of use, and mechanisms for interaction between BHUs and regulatory centers. In addition, promoting the PHC’s role in managing waiting lists for specialized care (with monitoring and care for users awaiting access), as well as expanding the adoption of clinical and referral protocols in PHC, linking them to strategies such as Telehealth.

As is well-known, the FHS still maintains a significant distance and limited interaction with professionals in regulatory centers, where decisions concerning access to specialized actions and services are made in a manner that is detached from the unique reality of users and the expectations of PHC teams. Although this type of strategy requires strong management support, technical preparation, and team time and availability, it can foster a more judicious use of specialized resources, broaden the PHC professionals’ perspective on the network, and foster greater connection and accountability for users on waiting lists, including the ability to dynamically monitor any changes in clinical status and work with management to ensure access.

c) Regarding the organization and operation of specialized care, the following are recommended:

Regulate the training of specialists, covering everything from the definition of positions and their distribution across regions based on the needs of SUS to the mandatory inclusion of medical residency curricula in different specialties in PHC, providing matrix support, to broaden specialists’ understanding of PHC, and develop support skills and a matrix culture.
Implement maximum waiting times for different care pathways, care stages, and specialties in different regions of the country, with corresponding monitoring, publicity, and incorporation into the financing, hiring, and contracting of providers.
Financing of specialized care, including, among other aspects, the mandatory implementation of matrix support (in-person and/or virtual) for PHC (enabling direct interactions between professionals from different services to resolve questions and manage cases), as well as integrated specialized care (rather than isolated procedures).
Build a progressive policy to strengthen specialized public care, such as the implementation and funding of regional polyclinics, to reduce the SUS dependence on the private market, including strengthening and placing the enormous potential of university hospitals at the service of SUS, and a greater regulation of the private sector in this area.

These proposals would have the potential not only to increase the availability of specialized care and the visibility of what happens in this space, but also to change its operating logic, which is often fragmented, influenced by private and market interests, marked by very little interaction with PHC and significant regional and inter-municipal inequalities. The National Specialized Care Policy (Política Nacional de Atenção Especializada - PNAES) partially addresses these proposals, notably through the “Integrated Care Offers (ICOs)” strategy - payment for the set of procedures and care technologies at key stages of care pathways, seeking to overcome the logic of payment for isolated procedures. However, its incremental implementation (in some specialties and phases of care), justified by the complexity of its shift in logic (from isolated procedures to integrated care), as well as the heavy reliance on private contracting (very necessary in the short and even medium term), requires careful consideration of the timing and direction of the changes that it may bring about.

d) Regarding the strategic nature of information for care coordination, given the multiplicity of systems and the slow pace of their effective interface and functional development, the following recommendations should be made:

Acceleration of collaborative strategies for producing innovations aimed at integration and interoperability between information systems used in PHC, specialized care, regulatory centers, and other services, to enable shared electronic medical records and facilitate care management, with the principles and needs of the SUS, prioritizing the health information technology market.

Although participation with the private sector is necessary in this area, new induction and regulatory frameworks are needed, as is investment in public development and innovation capacity focused on the SUS.

The proposed strategies, as can be seen, would focus on PHC, but they would also focus on specialized care and management, making it clear that care coordination within PHC can only be totally feasible if changes also occur in specialized services, as well as in the organization and management of the network and in structural policies. Evidently, each proposal requires an analysis of its technical, political, and financial feasibility, as well as any necessary adjustments, taking into account the problems and critical issues they seek to address and the objectives they aim to achieve.

It would be essential to develop a comprehensive strategy that combines the elements of the different proposals listed above, as well as other necessary ones. Furthermore, it should strongly consider the heterogeneity of PHC experiences, the scope and limits of the incremental nature of policies, and the degree of sustainability of innovative experiences. Even if drastic changes are not foreseen, including those due to structural elements beyond PHC that influence its conditions of possibility, it would be highly desirable to achieve a degree of uniformity and scope and a time-velocity that would have the power to effectively accumulate and open up a new avenue of possibilities in this field. Considering not only PHC, but also the demands and expectations of users, new initiatives in specialized care, and the more general situation of SUS management can be good guidelines in this regard.

Final considerations

We know the significant and fundamental contribution that Brazilian PHC, thanks to its extensive reach throughout the country, has made and can continue to make in accessing SUS, addressing inequalities, and managing chronic conditions and problems exacerbated by the pandemic and the precariousness of life.

In this sense, while we have much to celebrate, it is essential to recognize the limitations that still exist, such as those related to the coordination, continuity, and integration of care, which the population often experiences in the form of difficulties in accessing specialized services. This highlights that the consolidation of PHC depends on addressing important challenges faced by SUS, which involve regionalization and the establishment of specialized care within networks and their constraints.

This article sought to characterize care coordination, integration, and continuity devices that already exist or are under discussion in SUS; to identify critical entanglements, to examine key aspects for care coordination from the PHC perspective, and, finally, indicate a set of technical-political strategy proposals that, if implemented, could represent a material and symbolic accumulation for both PHC and SUS.

The FHS, due to its territorial and community-based nature, is an essential place for access, care, and protection of life. It has the potential to contribute to the establishment of new social relationships within SUS, public services, and the population, a significant achievement in light of Brazil’s multiple crises and democratic reconstruction. To achieve this, ensuring access, quality, and continuity of care is crucial.

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¹³ Ayres JR. Vulnerabilidade, Cuidado e integralidade: reconstruções conceituais e desafios atuais para as políticas e práticas de cuidado em HIV/Aids. Saude Debate 2022; 46(n. esp. 7):196-206.
¹⁴ Starfield B. Atenção Primária: equilíbrio entre necessidades de saúde, serviços e tecnologia. Brasília: MS; 2002.
¹⁵ Melo E, Mattos R. Gestão do Cuidado e Atenção Básica: controle ou defesa da vida. In: Mendonça MHM, Gondim R, Matta GC, Giovanella L, organizadores. Atenção Primária à Saúde no Brasil: conceitos, práticas e pesquisa. Rio de Janeiro: Editora Fiocruz; 2018.
¹⁶ McDonald KM, Sundaram V, Bravata DM, Lewis R, Lin N, Kraft AS, McKinnon M, Paguntalan H, Owens DK. Care Coordination. In: Shojania KG, McDonald KM, Wachter RM, Owens DK, editors. Closing the Quality Gap: A Critical Analysis of Quality Improvement Strategies. Technical Review 9. AHRQ Publication No. 04(07)-0051-7. Rockville: Agency for Healthcare Research and Quality; 2007.
¹⁷ Hartz ZMDA, Contandriopoulos AP. Integralidade da atenção e integração de serviços de saúde: desafios para avaliar a implantação de um "sistema sem muros". Cad Saude Publica 2004; 20(Supl. 2):S331-S336.
¹⁸ Munday B. Integrated social services in Europe. Strasbourg: Council of Europe Publ; 2007.
¹⁹ Haggerty JL, Reid RJ, Freeman GK, Starfield BH, Adair CE, McKendry R. Continuity of care: a multidisciplinary review. BMJ 2003; 327(7425):1219-1221.
²⁰ Cecilio LCDO, Reis AACD. Apontamentos sobre os desafios (ainda) atuais da atenção básica à saúde. Cad Saude Publica 2018; 34(8):e00056917.
²¹ Bousquat A, Giovanella L, Fausto MCR, Medina MG, Martins CL, Almeida PF, Campos SEM, Mota PHS. A atenção primária em regiões de saúde: política, estrutura e organização. Cad Saude Publica 2019; 35(Supl. 2):e00099118.
²² Almeida PFD, Medina MG, Fausto MCR, Giovanella L, Bousquat A, Mendonça MHMD. Coordenação do cuidado e Atenção Primária à Saúde no Sistema Único de Saúde. Saude Debate 2018; 42(n. esp. 1):244-260.
²³ Aleluia IRS, Medina MG, Almeida PFD, Vilasbôas ALQ. Coordenação do cuidado na atenção primária à saúde: estudo avaliativo em município sede de macrorregião do nordeste brasileiro. Cien Saude Colet 2017; 22(6):1845-1856.
²⁴ Kringos DS, Boerma WGW, Hutchinson A, Saltman RB, European Observatory on Health Systems and Policies, organizadores. Building primary care in a changing Europe. Copenhagen: European Observatory on Health Systems and Policies; 2015.
²⁵ Chaves ACC, Scherer MDDA, Conill EM. O que contribui para a resolubilidade na Atenção Primária à Saúde? Revisão integrativa da literatura, 2010-2020. Cien Saude Colet 2023; 28(9):2537-2551.
²⁶ Fausto MCR, Giovanella L, Mendonça MHM, Seidl H, Gagno J. A posição da Estratégia Saúde da Família na rede de atenção à saúde na perspectiva das equipes e usuários participantes do PMAQ-AB. Saude Debate 2014; 38:13-33.
²⁷ Magalhães Jr HM, Pinto HA. Atenção Básica enquanto ordenadora da rede e coordenadora do cuidado: ainda uma utopia? Saude Debate 2014; 51:4-7.
²⁸ Melo EA, Gomes GG, Carvalho JOD, Pereira PHB, Guabiraba KPDL. A regulação do acesso à atenção especializada e a Atenção Primária à Saúde nas políticas nacionais do SUS. Physis 2021; 31(1):e310109.
²⁹ Sousa ANA, Shimizu HE. Coordenação na Atenção Básica e integração na Rede de Atenção à Saúde: em que avançamos? Saude Debate 2024; 48(n. esp. 2):1-16.
³⁰ Silva Junior CL, Guabiraba KPDL, Gomes GG, Andrade CLTD, Melo EA. A regulação ambulatorial na Atenção Primária do Município do Rio de Janeiro, Brasil, a partir dos médicos reguladores locais. Cien Saude Colet 2022; 27(6):2481-2493.
³¹ Farias CML, Giovanella L, Oliveira AE, Santos Neto ETD. Tempo de espera e absenteísmo na atenção especializada: um desafio para os sistemas universais de saúde. Saude Debate. 2019; 43(n. esp. 5):190-204.
³² Gomes GG, Melo EA. A regulação do acesso à atenção especializada pela Atenção Primária à Saúde da cidade do Rio de Janeiro: coordenação ou competição? Physis 2023; 33(2).
³³ Machado JA, Guim ALS. Descentralização e igualdade no acesso aos serviços de saúde: o caso do Brasil. Rev Serv Publico 2017; 68(1)37-64.
³⁴ Cecilio LCDO, Carapinheiro G, Andreazza R, Souza ALMD, Andrade MDGG, Santiago SM, Meneses CS, Reis DO, Araújo EC, Pinto NRS, Spedo SM. O agir leigo e o cuidado em saúde: a produção de mapas de cuidado. Cad Saude Publica 2014; 30(7):1502-1514.
³⁵ Godoy CV, Rocha GDM. A territorialidade da Atenção Básica à Saúde do SUS: a difusão das clínicas médicas populares na Região Metropolitana de Belém, Pará, Brasil. Cien Saude Colet 2024; 29(4):e19742022.
³⁶ D'Amour D, Goulet L, Labadie JF, Martín-Rodriguez LS, Pineault R. A model and typology of collaboration between professionals in healthcare organizations. BMC Health Serv Res 2008; 8:188.
³⁷ Malta DC, Merhy EE. O percurso da linha do cuidado sob a perspectiva das doenças crônicas não transmissíveis. Interface (Botucatu) 2010; 14(34):593-606.
³⁸ Campos GWDS, Domitti AC. Apoio matricial e equipe de referência: uma metodologia para gestão do trabalho interdisciplinar em saúde. Cad Saude Publica 2007; 23(2):399-407.
³⁹ Hori AA, Nascimento ADF. O Projeto Terapêutico Singular e as práticas de saúde mental nos Núcleos de Apoio à Saúde da Família (NASF) em Guarulhos (SP), Brasil. Cien Saude Colet 2014; 19(8):3561-3571.
⁴⁰ Araujo TV, Pires SR, Bandiera-Paiva P. Adoção de padrões para Registro Eletrônico em Saúde no Brasil. RECIIS 2014; 8(4):554-566.
⁴¹ Cunha GT, Campos GWDS. Apoio Matricial e Atenção Primária em Saúde. Saude Soc 2011; 20(4):961-970.
⁴² Santos TLAD, Penido CMF, Ferreira Neto JL. A dimensão técnico-pedagógica do apoio matricial no Núcleo de Ampliado de Saúde da Família e Atenção Básica (Nasf-AB). Interface (Botucatu) 2022; 26:e210810.
⁴³ Treichel CADS, Campos RTO, Campos GWDS. Impasses e desafios para consolidação e efetividade do apoio matricial em saúde mental no Brasil. Interface (Botucatu) 2019; 23:e180617.
⁴⁴ Barros DM, Batista SMS, Pereira SS, Nunes RM, Pessanha RBA, Ribeiro JCES, Chagas ARP, Chagas LB, Puertas ABNA. Diálogos entre serviços: estratégias de integração e qualificação do cuidado em saúde - relato de experiência em Quissamã (RJ). In: Fernandes VR, Magalhães MG, D´Oliveira CBLC, Campos Filho E, Sergio JV, Silva JPV, Amorim AC, Jardineiro JC, Machado KS, organizadores. IdeiaSUS: saberes e práticas nos territórios do Sistema Único de Saúde. Rio de Janeiro: Cebes, 2020. p. 69-95.
⁴⁵ Pinheiro LP, Emerich BF. Cuidado compartilhado em Saúde Mental: o que dizem os trabalhadores? Interface (Botucatu) 2024; 28:e230324.
⁴⁶ Coelho Neto GC, Andreazza R, Chioro A. Integração entre os sistemas nacionais de informação em saúde: o caso do e-SUS Atenção Básica. Rev Saude Publica 2021; 55:93.

Data availability statement
The data sources adopted in the research are indicated in the article’s body.

Chief editors:
Maria Cecília de Souza Minayo, Romeu Gomes, Antônio Augusto Moura da Silva, Vania de Matos Fonseca

Data availability

The data sources adopted in the research are indicated in the article’s body.

Publication Dates

Publication in this collection
09 Jan 2026
Date of issue
Dec 2025

History

Received
22 Aug 2025
Accepted
25 Aug 2025
Published
27 Aug 2025

Este é um artigo publicado em acesso aberto sob uma licença Creative Commons

[1] ¹ Brasil. Ministério da Saúde (MS). E-Gestor Atenção Primária: espaço para informação e acesso aos sistemas de Atenção Básica [Internet]. 2021 [acessado 2025 mar 27]. Disponível em: https://egestorab.saude.gov.br/paginas/acessoPublico/relatorios/relCoberturaAPSCadastro.xhtml
» https://egestorab.saude.gov.br/paginas/acessoPublico/relatorios/relCoberturaAPSCadastro.xhtml

[2] ² Giovanella L, Bousquat A, Schenkman S, Almeida PFD, Sardinha LMV, Vieira MLFP. Cobertura da Estratégia Saúde da Família no Brasil: o que nos mostram as Pesquisas Nacionais de Saúde 2013 e 2019. Cien Saude Colet 2021; 26(Supl. 1):2543-2556.

[3] ³ Macinko J, Mendonça CS. Estratégia Saúde da Família, um forte modelo de Atenção Primária à Saúde que traz resultados. Saude Debate 2018; 42(n. esp. 1):18-37.

[4] ⁴ Organisation for Economic Co-operation and Development (OECD). Primary Health Care in Brazil. Paris: OECD; 2021.

[5] ⁵ Mendonça MHM, Gondim R, Matta GC, Giovanella L. Os desafios urgentes e atuais da atenção primária à saúde no Brasil. In: Mendonça MHM, Gondim R, Matta GC, Giovanella L, organizadores. Atenção Primária à Saúde no Brasil: conceitos, práticas e pesquisa. Rio de Janeiro: Editora Fiocruz; 2018.

[6] ⁶ Oliveira FP, Vanni T, Pinto HA, Santos JTR, Figueiredo AM, Araújo SQ, Matos MFM, Cyrino EG. Mais Médicos: um programa brasileiro em uma perspectiva internacional. Interface (Botucatu) 2015; 19(54):623-634.

[7] ⁷ Souza LEPFD, Paim JS, Teixeira CF, Bahia L, Guimarães R, Almeida-Filho ND, Machado CV, Campos GW, Azevedo-e-Silva G. Os desafios atuais da luta pelo direito universal à saúde no Brasil. Cien Saude Colet 2019; 24(8):2783-2792.

[8] ⁸ Tesser CD, Norman AH. Repensando o acesso ao cuidado na Estratégia Saúde da Família. Saude Soc 2014; 23(3):869-883.

[9] ⁹ Costa VC, Baptista TWDF, Cunha MBD. O SUS em territórios vulnerabilizados: reflexões sobre violência, sofrimento mental e invisibilidades nas favelas do Rio de Janeiro. Saude Debate 2022; 46(135):974-986.

[10] ¹⁰ Fausto MCR, Almeida PFD, Bousquat A, Lima JG, Santos AMD, Seidl H, Mendonça MHM, Cabral LMS, Giovanella L. Atenção Primária à Saúde em municípios rurais remotos brasileiros: contexto, organização e acesso à atenção integral no Sistema Único de Saúde. Saude Soc 2023; 32(1):e220382pt.

[11] ¹¹ Fonseca JMD, Lima SML, Teixeira M. Expressões da precarização do trabalho nas regras do jogo: Organizações Sociais na Atenção Primária do município do Rio. Saude Debate 2021; 45(130):590-602.

[12] ¹² Coelho Neto GC, Antunes VH, Oliveira A. A prática da Medicina de Família e Comunidade no Brasil: contexto e perspectivas. Cad Saude Publica 2019; 35(1):e00170917.

[13] ¹³ Ayres JR. Vulnerabilidade, Cuidado e integralidade: reconstruções conceituais e desafios atuais para as políticas e práticas de cuidado em HIV/Aids. Saude Debate 2022; 46(n. esp. 7):196-206.

[14] ¹⁴ Starfield B. Atenção Primária: equilíbrio entre necessidades de saúde, serviços e tecnologia. Brasília: MS; 2002.

[15] ¹⁵ Melo E, Mattos R. Gestão do Cuidado e Atenção Básica: controle ou defesa da vida. In: Mendonça MHM, Gondim R, Matta GC, Giovanella L, organizadores. Atenção Primária à Saúde no Brasil: conceitos, práticas e pesquisa. Rio de Janeiro: Editora Fiocruz; 2018.

[16] ¹⁶ McDonald KM, Sundaram V, Bravata DM, Lewis R, Lin N, Kraft AS, McKinnon M, Paguntalan H, Owens DK. Care Coordination. In: Shojania KG, McDonald KM, Wachter RM, Owens DK, editors. Closing the Quality Gap: A Critical Analysis of Quality Improvement Strategies. Technical Review 9. AHRQ Publication No. 04(07)-0051-7. Rockville: Agency for Healthcare Research and Quality; 2007.

[17] ¹⁷ Hartz ZMDA, Contandriopoulos AP. Integralidade da atenção e integração de serviços de saúde: desafios para avaliar a implantação de um "sistema sem muros". Cad Saude Publica 2004; 20(Supl. 2):S331-S336.

[18] ¹⁸ Munday B. Integrated social services in Europe. Strasbourg: Council of Europe Publ; 2007.

[19] ¹⁹ Haggerty JL, Reid RJ, Freeman GK, Starfield BH, Adair CE, McKendry R. Continuity of care: a multidisciplinary review. BMJ 2003; 327(7425):1219-1221.

[20] ²⁰ Cecilio LCDO, Reis AACD. Apontamentos sobre os desafios (ainda) atuais da atenção básica à saúde. Cad Saude Publica 2018; 34(8):e00056917.

[21] ²¹ Bousquat A, Giovanella L, Fausto MCR, Medina MG, Martins CL, Almeida PF, Campos SEM, Mota PHS. A atenção primária em regiões de saúde: política, estrutura e organização. Cad Saude Publica 2019; 35(Supl. 2):e00099118.

[22] ²² Almeida PFD, Medina MG, Fausto MCR, Giovanella L, Bousquat A, Mendonça MHMD. Coordenação do cuidado e Atenção Primária à Saúde no Sistema Único de Saúde. Saude Debate 2018; 42(n. esp. 1):244-260.

[23] ²³ Aleluia IRS, Medina MG, Almeida PFD, Vilasbôas ALQ. Coordenação do cuidado na atenção primária à saúde: estudo avaliativo em município sede de macrorregião do nordeste brasileiro. Cien Saude Colet 2017; 22(6):1845-1856.

[24] ²⁴ Kringos DS, Boerma WGW, Hutchinson A, Saltman RB, European Observatory on Health Systems and Policies, organizadores. Building primary care in a changing Europe. Copenhagen: European Observatory on Health Systems and Policies; 2015.

[25] ²⁵ Chaves ACC, Scherer MDDA, Conill EM. O que contribui para a resolubilidade na Atenção Primária à Saúde? Revisão integrativa da literatura, 2010-2020. Cien Saude Colet 2023; 28(9):2537-2551.

[26] ²⁶ Fausto MCR, Giovanella L, Mendonça MHM, Seidl H, Gagno J. A posição da Estratégia Saúde da Família na rede de atenção à saúde na perspectiva das equipes e usuários participantes do PMAQ-AB. Saude Debate 2014; 38:13-33.

[27] ²⁷ Magalhães Jr HM, Pinto HA. Atenção Básica enquanto ordenadora da rede e coordenadora do cuidado: ainda uma utopia? Saude Debate 2014; 51:4-7.

[28] ²⁸ Melo EA, Gomes GG, Carvalho JOD, Pereira PHB, Guabiraba KPDL. A regulação do acesso à atenção especializada e a Atenção Primária à Saúde nas políticas nacionais do SUS. Physis 2021; 31(1):e310109.

[29] ²⁹ Sousa ANA, Shimizu HE. Coordenação na Atenção Básica e integração na Rede de Atenção à Saúde: em que avançamos? Saude Debate 2024; 48(n. esp. 2):1-16.

[30] ³⁰ Silva Junior CL, Guabiraba KPDL, Gomes GG, Andrade CLTD, Melo EA. A regulação ambulatorial na Atenção Primária do Município do Rio de Janeiro, Brasil, a partir dos médicos reguladores locais. Cien Saude Colet 2022; 27(6):2481-2493.

[31] ³¹ Farias CML, Giovanella L, Oliveira AE, Santos Neto ETD. Tempo de espera e absenteísmo na atenção especializada: um desafio para os sistemas universais de saúde. Saude Debate. 2019; 43(n. esp. 5):190-204.

[32] ³² Gomes GG, Melo EA. A regulação do acesso à atenção especializada pela Atenção Primária à Saúde da cidade do Rio de Janeiro: coordenação ou competição? Physis 2023; 33(2).

[33] ³³ Machado JA, Guim ALS. Descentralização e igualdade no acesso aos serviços de saúde: o caso do Brasil. Rev Serv Publico 2017; 68(1)37-64.

[34] ³⁴ Cecilio LCDO, Carapinheiro G, Andreazza R, Souza ALMD, Andrade MDGG, Santiago SM, Meneses CS, Reis DO, Araújo EC, Pinto NRS, Spedo SM. O agir leigo e o cuidado em saúde: a produção de mapas de cuidado. Cad Saude Publica 2014; 30(7):1502-1514.

[35] ³⁵ Godoy CV, Rocha GDM. A territorialidade da Atenção Básica à Saúde do SUS: a difusão das clínicas médicas populares na Região Metropolitana de Belém, Pará, Brasil. Cien Saude Colet 2024; 29(4):e19742022.

[36] ³⁶ D'Amour D, Goulet L, Labadie JF, Martín-Rodriguez LS, Pineault R. A model and typology of collaboration between professionals in healthcare organizations. BMC Health Serv Res 2008; 8:188.

[37] ³⁷ Malta DC, Merhy EE. O percurso da linha do cuidado sob a perspectiva das doenças crônicas não transmissíveis. Interface (Botucatu) 2010; 14(34):593-606.

[38] ³⁸ Campos GWDS, Domitti AC. Apoio matricial e equipe de referência: uma metodologia para gestão do trabalho interdisciplinar em saúde. Cad Saude Publica 2007; 23(2):399-407.

[39] ³⁹ Hori AA, Nascimento ADF. O Projeto Terapêutico Singular e as práticas de saúde mental nos Núcleos de Apoio à Saúde da Família (NASF) em Guarulhos (SP), Brasil. Cien Saude Colet 2014; 19(8):3561-3571.

[40] ⁴⁰ Araujo TV, Pires SR, Bandiera-Paiva P. Adoção de padrões para Registro Eletrônico em Saúde no Brasil. RECIIS 2014; 8(4):554-566.

[41] ⁴¹ Cunha GT, Campos GWDS. Apoio Matricial e Atenção Primária em Saúde. Saude Soc 2011; 20(4):961-970.

[42] ⁴² Santos TLAD, Penido CMF, Ferreira Neto JL. A dimensão técnico-pedagógica do apoio matricial no Núcleo de Ampliado de Saúde da Família e Atenção Básica (Nasf-AB). Interface (Botucatu) 2022; 26:e210810.

[43] ⁴³ Treichel CADS, Campos RTO, Campos GWDS. Impasses e desafios para consolidação e efetividade do apoio matricial em saúde mental no Brasil. Interface (Botucatu) 2019; 23:e180617.

[44] ⁴⁴ Barros DM, Batista SMS, Pereira SS, Nunes RM, Pessanha RBA, Ribeiro JCES, Chagas ARP, Chagas LB, Puertas ABNA. Diálogos entre serviços: estratégias de integração e qualificação do cuidado em saúde - relato de experiência em Quissamã (RJ). In: Fernandes VR, Magalhães MG, D´Oliveira CBLC, Campos Filho E, Sergio JV, Silva JPV, Amorim AC, Jardineiro JC, Machado KS, organizadores. IdeiaSUS: saberes e práticas nos territórios do Sistema Único de Saúde. Rio de Janeiro: Cebes, 2020. p. 69-95.

[45] ⁴⁵ Pinheiro LP, Emerich BF. Cuidado compartilhado em Saúde Mental: o que dizem os trabalhadores? Interface (Botucatu) 2024; 28:e230324.

[46] ⁴⁶ Coelho Neto GC, Andreazza R, Chioro A. Integração entre os sistemas nacionais de informação em saúde: o caso do e-SUS Atenção Básica. Rev Saude Publica 2021; 55:93.

Device	Definition
Care Lines	Strategy for organizing different care provided and care flows within the network, geared towards the production of healthcare in a systemic manner and focused on the needs of users, supported by clinical and referral protocols, aimed at specific audiences, life cycles, or health problems and conditions³⁷.
Matrix support	Personalization of relationships between “referring/requesting” professionals (generalists, in most cases) and specialists in the subject, through such practices as case discussion, joint care, and sharing of care, assuming integration and support between professionals/teams responsible for managing cases and specialists, representing an alternative to the logic of referral and transfer of care³⁸.
Unique therapeutic project	Strategy for singularity of care in cases with greater risk, complexity, challenging nature, and vulnerability, building and operationalizing care plans prepared by a multidisciplinary team and negotiated with users and caregivers/families, often involving different types of health services, together with social sectors and community actors³⁹.
Access regulation	Mediation strategy between demand for specialized actions (examinations, consultations, interventions, hospitalizations) and the supply of these actions, seeking to enable adequate access, with equity, transparency, and in a timely manner²⁸.
Co-management between services	Spaces-moments of interaction between actors (professionals, managers) of different types of health services in the network to discuss cases and problems, agree on flows and protocols, understand mutual realities, etc.
Electronic health record	Set of individualized health and care information about users throughout their lives, often accessed through tools, such as electronic medical records⁴⁰.