Long-Term Care Institutions: potentials and challenges of integration with Primary Health CareAbstract
The weak training to understand the demands of older adults in Long-Term Care Institutions raises questions about the supply and challenges for comprehensive care in Primary Health Care. The aim was to analyze professionals’ perception about the potentialities and challenges of integration between Long-Term Care Institutions and Primary Health Care (PHC) in providing care to older adults. This is an exploratory and qualitative research with 18 professionals from the PHC health team. Semi-structured interviews were conducted and analyzed using the Discourse of Collective Subject. The work process presents challenges, such as reception, problem-solving, procedures offered, gaps in organization. The potentialities highlighted are priority in care and institutional monitoring. The challenges contradict the potentialities such as lack of priority, difficulty in care and interaction between teams. The organization and coordination of care is suggested, based on the needs identified, considering the principles and guidelines of the Brazilian Health System and the Elderly Statute.
Key words:
Homes for the Aged; Primary Health Care; Aged
Resumo
A frágil formação para compreender as demandas de idosos em Instituições de Longa Permanência suscitam questionamentos sobre oferta e desafios para o cuidado integral na Atenção Primária à Saúde. Buscou-se analisar a percepção dos profissionais sobre as potencialidades e os desafios da integração entre Instituições de Longa Permanência para Idosos e Atenção Primária à Saúde (APS), na realização do cuidado aos idosos. Trata-se de pesquisa exploratória e qualitativa com 18 profissionais de equipe de saúde da APS. Realizadas entrevistas semiestruturadas que foram analisadas com Discurso do Sujeito Coletivo. O processo de trabalho apresenta desafios: acolhimento, resolução dos problemas, procedimentos ofertados, lacunas na organização. Aponta-se como potencialidades: prioridade no atendimento e acompanhamento institucional. Os desafios contradizem as potencialidades: falta de prioridade, dificuldade de atendimento e de interação entre as equipes. Sugere-se a organização e articulação do cuidado, a partir das necessidades identificadas, considerando os princípios e diretrizes do SUS e o Estatuto da pessoa idosa.
Palavras-chave:
Instituição de Longa Permanência para Idosos; Atenção Primária à Saúde; Idoso
Resumen
La escasa formación para comprender las demandas de las personas mayores en los centros de atención de larga estancia plantea interrogantes sobre la oferta y los desafíos para la atención integral en la Atención Primaria de Salud. Buscamos analizar la percepción de los profesionales sobre las potencialidades y los desafíos de la integración entre los centros de atención de larga estancia para personas mayores y la Atención Primaria de Salud (APS), en la prestación de cuidados a las personas mayores. Se trata de una investigación exploratoria y cualitativa con 18 profesionales del equipo de salud de la APS. Se realizaron y analizaron entrevistas semiestructuradas utilizando el Discurso del Sujeto Colectivo. El proceso de trabajo presenta desafíos: recepción, resolución de problemas, procedimientos ofrecidos y brechas en la organización. Se destacan las siguientes potencialidades: prioridad en la atención institucional y seguimiento. Los desafíos contradicen el potencial: falta de prioridad, dificultad en la prestación del servicio y en la interacción entre equipos. Se sugiere que la atención sea organizada y coordinada con base en las necesidades identificadas, considerando los principios y directrices del SUS y del Estatuto del Adulto Mayor.
Palabras clave:
Institución de cuidados de larga estancia para personas mayores; Atención Primaria de Salud; Anciano
Introduction
There is a significant and intense increase in the number of older adults in the world, which causes a rapid aging of the population. This fact has become one of the greatest challenges for society and is directly related to the development and living conditions of people. Studies show that older adults will reach 83 years of age in developed countries and 74 years of age in developing countries between 2045 and 20501. There is even an increase of almost a year in the global healthy life expectancy at birth, going from 61.3 years in 2010 to 62.2 years in 2021, even with a sharp loss in 2019 due to COVID-192.
The aging process is directly related to socioeconomic and sociocultural issues of insertion in society, i.e., aging is strictly concerned with the way of life of older adults, constituted in the daily production mode of this society and how each older adult translates it into their subjectivity3.
As the aging process is unique, there are those who, for numerous reasons such as genetics, living conditions, race, sociodemographic problems, among others, present more intense functional cognitive declines, becoming dependent on care. In the Brazilian reality, many of these older adults stay in Nursing Homes, Asylums or Long-Term Care Institutions (LTCI), which care for this portion of the population, with the most varied degrees of needs, requiring greater care and attention from the Brazilian Health System (in Portuguese, Sistema Único de Saúde - SUS)4.
However, even with physical and cognitive changes, the aging process has become more active, making it essential to adopt care from the perspective of comprehensiveness so that user autonomy can be built, considering their needs, in the context of the family and the community5.
However, it is clear that professionals have not met the expectations of service users, who expect to be well treated by a committed and responsive healthcare professional, who meets their needs seriously and with a respectful approach, having access to care and having their doubts clarified so that they have better results in their healthcare6.
In addition to the lack of specific plans and the applicability of actions aimed at the elderly population, there is a lack of knowledge among health teams who do not know the best way to offer quality services, both for dependent and independent older adults, going against the principles of the organization of SUS care, based on universality, equity and comprehensiveness. There are limits to the operationalization of the Brazilian National Health Policy for Older Adults (in Portuguese, Política Nacional de Saúde da Pessoa Idosa - PNSPI), namely: unpreparedness and little appropriation of the policy by professionals and managers; existing actions are incipient; planning has been insufficient, and what was planned does not always occur from the perspective of co-management with Family Health teams (FHt) and based on the territory’ needs, generating a policy with little impact on teams’ practices5.
When addressing institutionalized older adults’ health, there are services and actions that should and can be developed by interrelating them to all sectors of society. However, the relationship between LTCIs and Primary Health Care (PHC) services is not easily operationalized in practice. Managers recognize that LTCIs are important and the responsibility of the Municipal Health Department (MHD). However, managers are unaware of the policies that need to be implemented. When they mention what they do in terms of healthcare for older adults, they focus on general care for hypertensive and diabetic patients, and do not address specific issues7.
Thus, there are major challenges to be overcome for the real operationalization of policies, which may show us the ineptitude and lack of interest of some managers and professionals8.
Therefore, the aim is to analyze professionals’ perception of the potential and challenges of integration between LTCIs and PHC in providing care to older adults.
Methods
This is an exploratory study with a qualitative approach. As it is a little understood and researched topic, the exploratory study helped to understand the potential and challenges of integrating LTCI and PHC in providing care to older adults9.
In this investigation, it was relevant to understand healthcare professionals’ view about the care provided to older adults in LTCI through a qualitative approach, as it revealed the conceptions and care processes developed, in addition to capturing the possibilities and limits of this care.
In accordance with Resolution 196/1996, Resolution 466 of December 12, 2012 and Resolution 510 of April 7, 2016, the project was forwarded to the Faculdade de Medicina de Marília Research Ethics Committee (REC). It was approved under Opinion 5,625,596 and Certificate of Presentation for Ethical Consideration 59716722.8.1001.5413 on September 5, 2022.
The information collected was stored in a physical and digital space restricted to researchers. With the Informed Consent Form, participants had full knowledge about the research carried out, the risks and benefits for themselves and others so that they could accept or not participate in the research. Secrecy and confidentiality were maintained in accordance with ethical aspects, and the COnsolidated criteria for REporting Qualitative research (COREQ) checklists were observed as a support tool10.
The study was carried out at the Health Center (Medical Specialties Center) responsible for LTCI of a small municipality in the Brazilian Center-West of São Paulo, which has 14,069 inhabitants, forming part of the Regional Health Department (RHD) IX, composed of 62 municipalities.
The municipality’s SUS is formed by the Central Health Center (HC), where the study was carried out, two Family Health Strategy (FHS) teams, and a Basic Health Unit (BHU), which functions as a support center for one of the FHS, since the populations of districts were unified to form the FHS. Moreover, it has a Psychosocial Care Center (in Portuguese, Centro de Atenção Psicossocial - CAPS I), a specialty center, a diagnostic center, a health department, and seven private establishments. The central BHU is the preferred contact for users, the main gateway and communication center with the entire Healthcare Network (in Portuguese, Rede de Atenção à Saúde - RAS), located in the city center, guaranteeing population access and attention to quality healthcare.
The municipality has a LTCI that is located in the territory under the responsibility of HC. Currently, the institution has a maximum capacity of 18 older adults, ten women and eight men, of whom four are completely dependent for their daily activities.
The professionals who make up the PHC team responsible for the territory where LTCI is inserted in the municipality studied were invited to participate in the research.
Healthcare team professionals who had been in the same role for at least six months and who belonged to the same LTCI territory, with at least one representative from each professional category, were included.
Professionals who were on vacation or away due to health problems at the time of data collection were excluded.
The PHC team invited to participate in the research was made up of: three general practitioners; a neurologist; a cardiologist; an orthopedist; a psychiatrist; a nutritionist; a psychologist; a speech therapist; a dentist; two nursing assistants, responsible for the dressing room and the materials center; one nursing assistant, responsible for the examination room; four nursing assistants for the vaccination room; six nursing assistants to perform patient triage; two nurses in charge; one nurse responsible for health surveillance; and two social workers. Moreover, there were four people responsible for epidemiological surveillance, one telephone operator, two employees for releasing medical records, three for scheduling appointments, two for scheduling ambulances, three in the administrative sector, six drivers and four employees for general services, totaling 54 professionals.
After the health team was approached and clarified about the topic and importance of the research for the municipality, 18 professionals agreed to participate in data collection. The others did not agree to participate due to issues such as the location of data collection, knowledge of LTCI and professionals who work at the institution, strong political involvement with management, lack of knowledge on the subject and insecurity, in addition to a lack of interest in issues related to the municipality’s PHC.
Depending on professionals’ acceptance, the best day and time for the interview was scheduled. At this point, a location farther away from the large flow of people was chosen or one where the interviewee felt most comfortable answering the questions, usually the place where they worked.
Data collection took place through semi-structured interviews11, with a script containing questions related to the work process, together with LTCI, care, the potentialities and challenges between PHC and LTCI, requesting an example of this practice.
Interviews were initiated, preliminarily as a pilot, with professionals from the same service to be researched, to verify the instrument and train interviewers, with no need for modifications to the instrument, with subsequent continuation of interviews with participants. The first author conducted the interviews under the supervision of a researcher with a PhD and experience in qualitative research.
The audio-recorded interviews took place between September 21, 2022, and February 23, 2023. They lasted, on average, 17 minutes, with a minimum of 11 minutes and a maximum of 40 minutes.
Data analysis was performed using the Discourse of Collective Subject (DCS), based on the Theory of Social Representations (TSR)12,13. After the interviews were conducted, the audios were transcribed for later identification of key expressions (KEs) and central ideas (CIs) of each segment. CIs were then grouped and classified according to the meanings and objective of the research, which is the work process between PHC and LTCI.
Once the CIs were grouped and classified, DCSs were prepared, which served to foster discussion and the research hypothesis. DCSs were numbered according to their respective CIs.
Results
Participants in the survey believe that older adults at LTCI are well cared for by HC professionals, in general, receiving priority in the flow of care, without needing to schedule an appointment when they seek the service, and generally receiving medical care and vaccinations. However, when care was provided at LTCI, they consider that it was more positive for older adults. They highlight that dentistry has developed projects for prosthesis care and general oral health. They mention that the most positive aspect of the care provided by professionals is affection and conversation with older adults (Chart 1).
As for the challenges (Chart 2), participants discussed the lack of demand for healthcare services by LTCI professionals, since the institution has its own team to offer basic care to older adults. They described that the low demand for support from HC is focused on the choice of LTCI because they develop care at the institution itself, seeking care at HC only in cases of emergency.
In general, the working relationship between LTCI and HC is often complex and confusing. It is clear that LTCI professionals have difficulty reporting on the health status of older adults at the time of care. They also mention the lack of willingness of HC workers, in general, to offer more specific and humane care to institutionalized older adults, who are not a priority when they arrive at HC.
However, it is also possible to identify the representation that it is HC professionals who do not show concern for older adults of LTCI and do not provide regular care at the institution, focusing more on routine and less on actions to prevent diseases. The lack of closeness with LTCI is also seen as a lack of empathy, patience, complacency and resistance to change, leading to a lack of knowledge of older adults’ needs.
In professionals’ representation, older adults are people “forgotten” by their families, being an invisible population, remaining in the institution until they die.
They described that they do not have the skills to develop care for older adults, requiring training.
Discussion
As potentialities, the provision of care by the nursing team, the priority of care during medical consultations, the clinical control carried out by LTCI professionals and the importance of the work itself stood out.
However, when analyzing the potentialities and challenges, there are contradictions between discourses, when representing the provision of care by HC professionals in a qualified manner, but at the same time, there is the counterposition of the representation that they are not responsible for LCTI adults.
It is clear that LTCI professionals seek access to care in the health unit; however, there is no co-responsibility in the development of care by HC professionals. Furthermore, there is alternation of managers in LTCI, which can also make it difficult to build integration.
This lack of closeness between HC and LTCI professionals is seen as a lack of empathy, complacency and resistance, i.e., workers from both institutions would have to understand and structure care based on established needs, with a commitment to care, creating a bond with PHC service users.
The representation of older adults being seen as people “forgotten” by families, being an invisible population, “remaining in the institution until they die” can also determine this lack of co-responsibility.
Understanding old age as synonymous with incapacity and/or illness is one of the greatest social stigmas related to aging. This view of being an older adult causes several emotional harms, since older adults end up being excluded, in addition to losing their autonomy, both by society in general and by their own family members, who understand the loss of individuals’ ability to respond for themselves after a certain age, and this cannot be generalized14.
Currently, one of the major challenges for the public sector is caring for older adults. Older adults should not be left solely under the care of their family members. New family configurations and new demands for caring for older adults force us to think about offering home care, support for carrying out activities, promoting autonomy, preventing diseases and quality of life15.
In Brazil, LTCIs are the most common way to meet the elderly population’s needs, who do not have third-party assistance to maintain their routine activities or do not have the financial means to pay for a professional to assist with their activities. In view of this, it is necessary to assess and discuss proposals to improve the quality of provision of these services, free of charge, or at least to make them more accessible to everyone16.
When analyzing how the provision of care for older adults is developed between Eastern and Western countries, it is clear that in some European countries, such as England and Denmark, the focus is on rehabilitation, quality of life, shorter treatment time and less institutionalization, since there are different ways for older adults to receive the necessary care in their own homes, rather than in LTCI. In fact, this type of care for older adults is often dispensed with. The State and municipality are responsible for care, providing all the financial support family needs to offer the best and most dignified care17.
In the municipality under investigation, older adults in LTCI are cared for by a HC, which is characterized by the care provided by specialist physicians, and is called a central BHU, when, according to PHC policies, it should be provided by a FHt. This care provided by the municipality could be organized considering the logic of network care. In other words, initial and preferential access would be through FHS, with referrals to specialties, when necessary, even causing confusion within the team regarding what care should be offered, based on what health needs, whether or not older adults should be prioritized, how and in which situations referrals should be made.
Other aspects identified were the care for older adults without capturing their specificities, as adults and older adults, as well as the care model centered on curative medical care, without health promotion, disease prevention and with difficulties in monitoring older adults’ health status. In other words, the care model is biomedical and fragmented, not constituting comprehensiveness with users and in the health system organization.
Reflecting on this context, it is also necessary to think about public policies and the ways in which the municipality can implement them to improve the quality of care for the elderly population, structuring the service to meet the needs in the territory and in the RAS. There is a lack of system operationalization according to regionalization and territorialization, PHC should be the preferred gateway to the SUS, with prioritization of care and operation of the RAS, based on needs with expanded diagnosis and treatment.
Organizing care in a network for older adults is a challenge, articulating the various existing social services and equipment in health territories to meet their needs18.
The transition of care between different points of care in the RAS is also a problem in Brazil and in other countries, in order to meet people’s needs. In Portugal, it was identified that there are challenges regarding long-term care, with rehabilitation and lifestyle changes, since, after the pandemic, services are having difficulty organizing themselves due to a lack of professionals and resources, in addition to lack of motivation, making it imperative to train professionals to carry out the necessary actions in the face of the complexity of social and health needs, being a multidimensional practice19.
The research carried out mentions: lack of training for healthcare professionals; difficulty in transporting older adults to HC; lack of organization that allows HC professionals to go to LTCI, due to the high demand for care at HC; lack of a multidisciplinary team at LTCI itself; and even the lack of openness for HC to act.
The approach to older adults has changed over time, in line with changes in public employment and health policies. There were important changes related to aging in the update of the Brazilian National Primary Care Policy (in Portuguese, Política Nacional da Atenção Básica - PNAB) in 2017, making it clear that care for older adults within the FHt territory is mandatory, including those who are domiciled and institutionalized, whether in a private institution or not. Therefore, FHS must develop activities together with the institution. However, there is no recognition of LTCIs in FHS territories and the activities are insufficient for these older adults’ health needs20.
In the investigation into PNSPI implementation in a medium-sized municipality in the countryside of São Paulo, Brazil, it was found that there was no specific municipal plan for older adults. The Municipal Health Plan included the goal of “Implementing the Older Adults Health Program” and implementing the PNSPI in the Annual Management Report. However, actions such as medical consultations were identified, but without specificity for older adults and little involvement from the team5.
Municipal, state and federal managers need to discuss the applicability and suitability of these policies so that they can be put into practice, in other words, to provide a more dignified and healthy old age, providing access and resolving needs, overcoming the biomedical model of care. It is also necessary to develop actions to promote health and prevent common diseases, bearing in mind the State’s obligation towards older adults’ health, as clearly presented in the Elderly Statute21.
The research results showed that communication and integration between LTCI and HC teams are interfering in the care provided. Thus, it is important for professionals to understand the real needs and to be able to build strategies that meet both services and, mainly, the people to be cared for.
In Spain, a country with a high longevity, it has also been found that there are difficulties in the communication process between Nursing Homes and the PHC service. PHC professionals are unaware of how Nursing Homes operate, the clinical situation and the older adults’ needs, and only carry out prescriptions of physicians at the Nursing Homes, focusing too much on bureaucratic situations. There is a clear need for better interaction between the two services for integrated planning of interventions, with periodic meetings and training of professionals to standardize care criteria22.
Within a context of challenges, in the organization of networked care, articulating the various existing social services and equipment in health territories, the idea of health needs stands out, which are of a social nature, worked on individually and collectively. They are organized in taxonomy, with the objective of organizing and operationalizing the care offered, identifying to what extent these needs are actually heard and understood by healthcare service professionals23.
The aim is to build care from the perspective of comprehensiveness in the different spheres of health. The health team builds care through qualified listening, preparing itself in the best possible way to perceive the needs brought, individually, by users. It is understood that this comprehensiveness will not be fully contemplated in healthcare services, but it can be articulated in the different sectors, improving living and care conditions and being thought of in a broader (“macro”) way, in healthcare service networks23.
Given the Brazilian scenario of healthcare for older adults, there is a proposal for a care model focused on special and particular needs and characteristics. The model is structured in five levels. Level one represents reception, establishment of bonds and trust. Level two includes educational actions, health promotion, disease prevention and health recovery for families of low-risk older adults, community centers, rehabilitation services, care and self-care support and support for family members. Level three involves a multidisciplinary assessment (physician, nurse and social worker) of older adults so that specific interventions can be implemented with home and outpatient care. Levels four and five represent short-term care units (home care, emergency, hospitals, etc.) and long-term care units (rehabilitation unit, assisted living and LTCI), respectively. An important point of the care model is the correct recording of all stages, not only of clinical evolution, but also of the participation of older adults in the proposed activities24.
It is important to articulate this care model for older adults24 considering the context of RAS, in its implementation, the aim is to ensure continuity of care for those with chronic diseases, for example, in order to obtain better results in terms of epidemiology and comprehensive care. Different points of PHC, of medium and high complexity, need to be interconnected without barriers in accessing services, being coordinated by PHC, according to what would be most important for people, offering care and technology that can solve problems in a given space25.
Healthcare for the elderly population can be restructured, based on overcoming the model focused only on disease and moving towards building comprehensive care in the healthcare network, allowing for quality care at a sustainable cost. However, all social actors involved in the process must understand the importance of changes, in addition to seeing themselves as part of it. In other words, the leading role of team professionals, older adults, other sectors besides health and organized civil society is needed to manage not the disease, but individuals, with appropriate use of available technologies. To this end, it is necessary to train professionals to act in care based on these technologies and centered on the person, with quality information and frequent monitoring26.
Final considerations
The study allowed for an understanding of professionals’ perspective on integration, its challenges and potential between PHC and LTCI. The social representations that emerged throughout the discourses revealed how care occurs, but also the limitations of care offered by professionals in the institution, justified by the high demand for care in HC, which makes it impossible for professionals to travel to LTCI.
Still regarding the challenges, speeches reveal some stigmas related to the representation of institutionalized older adults in the sense that there are not many prospects for quality of life and how to develop care based on their needs. There is also a lack of knowledge among HC professionals in meeting the demands of institutionalized older adults, in addition to the lack of interest that some demonstrate in relation to training. In general, the work process does not prioritize institutionalized older adults, nor those at home, making it necessary to review the care proposal, the relationship between LTCI and the health work process, from the perspective of care in the context of the RAS.
In relation to the potential, it is clear that there is priority when older adults seek activities at HC and, in certain situations, they do not need to schedule the service, with the care provided by the nursing staff and the community health workers for these older adults being positive. In the dentistry sector, there is a project to perform prosthetics and oral health prevention.
The process related to the development of the research made it possible to prepare a technical product that included the presentation of the findings with the municipal management for the construction of care strategies to be offered to older adults at LTCI, with the intention of organizing care in a network, based on the needs identified, considering the principles and guidelines of the SUS and the Elderly Statute.
The possibility of working with a municipality is identified as a limit of the investigation, making it necessary to expand the research with other subjects that participate in the implementation of the policy in the municipalities and in other locations so that it is possible to understand how the integration between LTCI and PHC has occurred.
References
- 1 Fundação da População das Nações Unidas (UNFPA). Resumo executivo - Envelhecimento no século XX: Celebrações e Desafios. New York: UNFPA; 2012.
- 2 GBD 2021 Diseases and Injuries Collaborators. Global incidence, prevalence, years lived with disability (YLDs), disability-adjusted life-years (DALYs), and healthy life expectancy (HALE) for 371 diseases and injuries in 204 countries and territories and 811 subnational locations, 1990-2021: a systematic analysis for the Global Burden of Disease Study 2021. Lancet 2024; 403(10440):2133-2161.
- 3 Barroso EP. Reflexões sobre a velhice: identidades possíveis no processo de envelhecimento na contemporaneidade. Hist Oral 2021; 24(1):9-27.
- 4 Souza KS, Castro JLC, Araujo LF, Santos JVO. Representações sociais do envelhecimento: um estudo com avós idosas que cuidam de netos e avós que não. Cien Psicol 2018; 12(2):293-297.
- 5 Damaceno MJCF, Chirelli MQ. Implementação da Saúde do Idoso na Estratégia Saúde da Família: visão dos profissionais e gestores. Cien Saude Colet 2019; 24(5):1637-1646.
- 6 Oster A, Wiking E, Nilsson GH, Olsson CB. Patients' expectations of primary health care from both patients' and physicians' perspectives: a questionnaire study with a qualitative approach. BMC Prim Care 2024; 25:128.
- 7 Zen D, Leite MT, Hildebrandt LM, Silva LAA, Van der Sand ICP. Políticas de atenção a idosos na voz de gestores municipais de saúde. Rev Gaucha Enferm 2018; 39:e62502.
- 8 Damaceno NA, Lima MADS, Pucci VR, Weiller TH. Redes de Atenção à Saúde: uma estratégia para integração dos sistemas de saúde. Cien Saude Colet 2019; 24(5):1637-1646.
- 9 Gil AC. Como elaborar projetos de pesquisa. São Paulo: Atlas; 2002.
- 10 Tong A, Sainsbury P, Craig J. Consolidated criteria for reporting qualitative research (COREQ): a 32- item checklist for interviews and focus group. Int J Qual Heal Care 2007; 19(6):349-357.
- 11 Minayo MC. O desafio do conhecimento: pesquisa qualitativa em saúde. São Paulo: HUCITEC; 2014.
- 12 Lefevre F, Lefevre AMC. Discurso do Sujeito Coletivo: representações sociais e intervenções comunicativas. Texto Contexto Enferm 2014; 23(2):502-507.
- 13 Zermiani TC, Freitas RS, Ditterich RG, Giordani RCF. Discourse of the Collective Subject and Content Analysis on qualitative aproach in Health. Res Soc Dev 2021; 10(1):e57310112098.
- 14 Anes E, Alves P, Sousa F, Antão C. Alterações auto-percecionadas no envelhecimento: gestão das emoções. Inst Poli Brag 2019; 241-246.
- 15 Minayo MCS. O imperativo de cuidar da pessoa idosa dependente. Cien Saude Colet 2019; 24(1):247-252.
- 16 Guimarães MRC, Giacomin KC, Ferreira RC, Vargas AMD. Avaliação das Instituições de Longa Permanência para Idosos no Brasil: um panorama das desigualdades regionais. Cien Saude Colet 2023; 28(7):2035-2050.
- 17 Minayo MCS, Mendonça JMB, Sousa GS, Pereira TFS, Mangas RMN. Políticas de apoio aos idosos em situação de dependência: Europa e Brasil. Cien Saude Colet 2021; 26(1):137-146.
- 18 Andrade MI, Sales AAS, Fernandes ARK, Ramos DSS, Coelho ER, Coutinho ISC, Oliveira LLG, Oliveira RF, Rodrigues SJA. Desafios para a integralidade da assistência à pessoa idosa nos serviços da atenção primária à saúde. Braz J Hea Rev 2023; 6(1):954-957.
- 19 Ferreira R, Pedrosa AR, Reis N, Sousa L, Nicolau C, Ferreira B, Rocha B, Baixinho CL. Transitional care for older persons with need of geriatric rehabilitation nursing interventions. BMC Nurs 2024; 23:376.
- 20 Morosini MVGC, Fonseca AF, Baptista TWF. Previne Brasil, Agência de Desenvolvimento da Atenção Primária e Carteira de Serviços: radicalização da política de privatização da Atenção Básica? Cad Saude Publica 2020; 36(9):1-20.
- 21 Oliveira ACD, Giacomin KC, Santos WJ, Firmo JOA. A percepção do usuário idoso sobre o acesso e a qualidade da Atenção Primária à Saúde. Rev Bras Med Fam Comunidade 2022; 17(44):2363.
- 22 Coba AC, Aparicioa BA, Palaoa GS, Chacóna CP, Grijalbaa PL, Martínez PF. Atención sociosanitaria en una residencia urbana sanitarizada y el papel de Atención Primaria. Estudio cualitativo con residentes, familiares y profesionales. Atención Primaria 2023; 55:102529.
- 23 Cecílio LCO. As necessidades de saúde como conceito estruturante na luta pela integralidade e equidade na atenção. In: Pinheiro R, Mattos RA. Os sentidos da integralidade na atenção e no cuidado à saúde. Rio de Janeiro: IMS ABRASCO; 2001. p.113-126.
- 24 Veras RP, Oliveira M. Envelhecer no Brasil: a construção de um modelo de cuidado. Cien Saude Colet 2018; 23(6):1929-1936.
- 25 Tofani LFN, Furtado LAC, Guimarães CF, Feliciano DGCF, Silva GR, Bragagnolo LM, Andreazza R, Chioro A. Caos, organização e criatividade: revisão integrativa sobre as Redes de Atenção à Saúde. Cien Saude Colet 2021; 26(10):4769-4782.
- 26 Veras PR. Modelo assistencial contemporâneo para os idosos: uma necessidade premente. Rev Bras Geriatr Gerontol 2022; 25(3):1-22.
