Implementation of the Family and Community Medicine and Multidisciplinary Family Health Residency programs of the Municipal Health Department of Campo Grande-MS, BrazilAbstract
Although there is an increase in the number of medical residency vacancies in family and community medicine, there is still poor distribution. These residency programs present cooperation with the Oswaldo Cruz Foundation through actions based on and applicable in practice, with the innovation of assistance technologies. Results show growth in the evolution of medical, nursing and dental care, with percentages of 86.94%, 81.97%, 81.80% and 66.00%, respectively. Improving the quality of records, changing the work process in dentistry and empowering nursing, with care protocols, are the main results.
Key words: Primary care; Multidisciplinary residency; Family and community medicine
Resumo
Embora haja aumento do número de vagas de residência médica em medicina de família e comunidade, ainda há má distribuição. Esses programas de residência apresentam uma cooperação com a Fundação Oswaldo Cruz através de ações embasadas e aplicáveis na prática, com a inovação de tecnologias assistenciais. Resultados mostram crescimento na evolução dos atendimentos médicos, de enfermagem e odontológicos, com percentuais de 86,94%, 81,97%, 81,80% e 66,00%, respectivamente. A melhoria da qualidade do registro, a mudança do processo de trabalho na odontologia e o empoderamento da enfermagem, com protocolos assistenciais são os principais resultados.
Palavras-chave: Atenção primária; Residência multiprofissional; Medicina da família e comunidade
Resumen
Aunque hay un aumento en el número de vacantes de residencias médicas en medicina familiar y comunitaria, todavía hay una mala distribución. Estos programas de residencia presentan cooperación con la Fundación Oswaldo Cruz a través de acciones basadas y aplicables en la práctica, con la innovación de tecnologías asistenciales. Los resultados muestran un crecimiento en la evolución de la atención médica, de enfermería y odontológica, con porcentajes del 86,94%, 81,97%, 81,80% y 66,00%, respectivamente. Mejorar la calidad de los registros, cambiar el proceso de trabajo en odontología y empoderar a la enfermería, con protocolos de atención, son los principales resultados.
Palabras clave: Atención primaria; Residencia multidisciplinaria; Medicina familiar y comunitaria
Introduction
Health systems based on powerful primary health care (PHC) have more reliable health indicators, greater equity in health care, lower costs, more effective systemic coordination, and greater safety for users1,2, much like the presence of a health professional specialized in PHC makes it more effective1.
Data from 2020 shows that there are a little over 7,000 family and community doctors in Brazil5. The number of nurses and dentists with a specialization or residency in PHC is even smaller. It is well-known that these deficiencies are related to the teamwork model exemplified in patient-centered medical care, which can generate inefficiency and restricted access3. Although there is a substantial increase in the number of medical residency (MR) openings in Family and Community Medicine (FCM) in recent years, the poor distribution and occupancy rate of these openings is still a challenge, especially when one considers the more than 40,000 Family Health Teams (FHT) that exist in the country4,5.
Based on the expanded concept of health, described by the World Health Organization (WHO), with the interaction between physical, psychological, and social wellbeing, based on social determinants referenced by the Brazilian Unified Health System (SUS), health services must align with the perspective of comprehensive care for the user in a multidisciplinary view of carrying out activities to fulfill the essential attributes of the first contact, longitudinality, comprehensiveness, and coordination of care6.
The first multidisciplinary family health residencies were created in 2002, even before the creation of the National Commission for Multidisciplinary Residency in Health (Comissão Nacional de Residência Multiprofissional em Saúde - CNRMS), which began the process of regulating multidisciplinary health residencies, which counted on just over 500 places in 2006, none of which were located in the Midwest region5.
For this scenario to be transformed nationally, an interaction took place between municipal management and federal educational entities, culminating in an expansion seeking to improve the qualification of the PHC network. With this, technical cooperation partnerships were set up with FIOCRUZ. The implementation of residency programs shows that the proposals implemented to expand the network consolidate the expansion of access to PHC. The provision and adequate professional training, the allocation of problem-solving technologies, and the improvement of regulation have led to the implementation of the necessary mediating role for PHC6.
The cooperation partnership between the Oswaldo Cruz Foundation (FIOCRUZ) and the municipality of Campo Grande, MS, Brazil, through the FIOCRUZ Center for Strategic Studies (Centro de Estudos Estratégicos - CEE) initially applied by the Innovation Laboratory Project in Primary Health Care (Projeto do Laboratório de Inovação na Atenção Primária à Saúde - INOVAAPS), and today coordinated by the Campo Grande - MS Integrated Health Care Territories Project (Projeto Territórios Integrados de Atenção à Saúde Campo Grande - MS - TEIAS), provides actions that are well-founded and applicable in practice, mainly through the innovation of care, management, and communication technologies, aiming to strengthen PHC within the scope of SUS7.
This scenario shows the need and importance of creating medical and multidisciplinary residency programs that seek to train professionals who are capable of working in PHC and capable of contributing to the strengthening of SUS in an in-service teaching training modality.
In the context of expansion of family and community medicine residency programs, the magnitude of growth remains active and reflects improved access to health in a comprehensive and equitable manner, in accordance with the principles of SUS8.
The perception of the existence of a “municipal school secretariat” is an approach that supports the in-service teaching model, as a possible path toward the training of health professionals in SUS, with the main organizational strategy being the family health strategy, presenting Residents as active participants in this process, thereby creating reflective spaces within the units9.
In a proposal to train health professionals, the multidisciplinary residency program seeks to build interdisciplinary practices capable of inserting the logic of the fragmentation of knowledge and practices in the characteristic at the forefront of health policies and work. However, this type of teaching and service requires conditions for its implementation or else it will merely become a potential training session in strictly rhetorical terms10.
One can see that the residency programs, as well as the PRMFC-Rio, provide a significant increase in the supply of doctors who are specialists in a given healthcare area, due to the strategies adopted, such as supplementary scholarships and inputs. Experience also shows that implementing a residency program in the midst of an intense PHC restructuring requires planning suited to the existing reality11. Therefore, the challenges for an organizational model involve the need for cultural change towards a managerial model in order to obtain results12.
It is important to highlight that the use of technological tools in real time increases the work generated, and combined with the decentralization of budgetary resources allocated to planning areas, makes the service more demanded by Primary Care managers due to the necessary monitoring of the indicators applied in the management contract12.
The main objective, therefore, was to present the results of the implementation, expansion of access, and consolidation of the Family and Community Medicine Medical Residency (Programas de Residências Médica de Medicina de Família e Comunidade - PRMFC) and Multidisciplinary Family Health (PRMSF) programs of the Municipal Health Department of the city of Campo Grande, Mato Grosso do Sul, Brazil, in the coordination of the TEIAS Project linked to CEE/FIOCRUZ.
Methodology
This is a cross-sectional quantitative descriptive study, which presents the results obtained in the process of building medical and multidisciplinary residency programs. Historically, public health has presented itself in different ways in the different regions of the country. The movement in defense of the SUS and in-service teaching, through health residencies, characterizes a standard of excellence for the training of health professionals who work in PHC. Therefore, based on the experience of the support provided by the FIOCRUZ institution with professionals from the Municipal Health Department of Campo Grande - MS (Secretaria Municipal de Saúde de Campo Grande - MS - SESAU), an exponential increase in access and quality in PHC can be observed.
At the end of 2019, with the need to qualify and expand primary care in Campo Grande, a cooperation project began, joining the Municipal Health Department, FIOCRUZ, and the Ministry of Health, called at that time the Care Innovation Laboratory Primary Health Care (Laboratório de Inovação de Atenção Primária em Saúde - LABINOVAAPS). This technical assistance sought, among other objectives, to support the implementation of multidisciplinary residency programs in family health, as a new program and in the expansion and qualification of the existing family and community medicine program.
At the beginning of 2020, the selection process took place, offering 116 openings, 76 for PRMSF and 40 for PRMFC. With 40 doctors enrolled in the PRMFC and PRMSF, the candidates were enrolled and divided into seven professional categories: nursing (33), dentistry (12), physical therapy (6), pharmacy (12), psychology (2), social services (6), and physical education (5). Of these residents, 85 were included in family health teams (FHTs, including doctors, nurses, and dentists) and the rest in the then NASF-AB teams. At the end of the two-year period, 103 residents had completed the programs, 68 from PRMSF and 35 from PRMFC.
From the second class onwards, the number of places offered by PRMSF was changed, dropping from 76 to 47. As a result, 87 places are offered annually in the two programs mentioned above, with all of the openings being completely filled. As shown in Table 1, we can observe the described quantities of offers, openings, graduates, and the projection for the current class, in the two programs covering the period from 2020 to 2024.
The descriptive analysis of the results of the implementation of the TEIAS Project used a public documentary source from the SUS data systems and municipal management reports, with the data extracted from the Primary Care Information and Management Platform, the e-Gestor Atenção System. The period covered was from January 2020 to December 2023. The analysis of the annual growth rate was carried out by calculating the equivalent of the difference between the current value of the procedures performed and their value in the previous year, divided by the current value in the previous year and then multiplied by 100 to obtain the percentage.
Results and discussion
The INOVAAPS Project originated in 2020, supporting the implementation of the PRMFC and PRMSF on the premise of strengthening the implemented strategies as regards the expansion of user access to SUS in the municipality of Campo Grande. The areas of greatest emphasis were surveillance and health promotion, guiding them to interact and identify problem situations for appropriate interventions for the scenario considered essential to the service.
However, seeking to continue and consolidate institutional development, the INOVAAPS project was restructured into the TEIAS Project, which has served to support the municipal manager, thus subsidizing the decision-making process, resolution, and structuring of both the work and professional training. This project was consolidated, with its two residency programs well-aligned, so much so that we present increasing results with the number of procedures performed, whether in the periods before the pandemic or after the pandemic10,12,13.
According to data extracted from the Primary Care Information and Management Platform, the Primary Care e-Manager, in December 2019, the period prior to the implementation of the Project, Primary Care in the municipality of Campo Grande had 125 FHTs implemented together with Oral Health Teams (OHTs), 10 teams in Traditional Primary Care and 11 Expanded Family Health and Primary Care Centers (Núcleos Ampliados de Saúde da Família e Atenção Primária - NASF-AP).
The sustained articulation between managers, a greater number of actions developed in the fields of practice, and the contractual disruption of management by municipal employees regarding the group of preceptors were actions carried out by the TEIAS Project. These actions corroborate applied methodologies, whether by other residency programs or by municipal managers, which show potential in training resident professionals, tutors, and preceptors, thereby helping health services to rethink their professional practices so as to qualify health actions based on theoretical subsidies13,14.
It is estimated that the population covered by FHTs in Primary Care in 2019 was 461,250 people. Of this total, the estimated population coverage by affiliated FHTs was 431,250 people, which registered the municipality with a PHC coverage of approximately 52%, ranked next-to-the-last in coverage among Brazilian capitals. Seeking to fill this deficit of health professionals specialized in PHC, as well as to guarantee increased coverage, multidisciplinary training in the state of Mato Grosso do Sul has gained strength in the number of openings in recent years, as presented in this work, which has a perspective of 40 graduates in the fields of pharmacy, dentistry, nursing, physical education, social services, physical therapy, and psychology, by 2025 and 47 future graduates expected for 2026.
Through the increase in the formulation of 229 FHTs and 11 PHC teams (PHCTs), approximately 88% of potential coverage was achieved, becoming part of the 10 best evaluated capitals in public health in Brazil, as can be seen in Table 2.
When the residency programs began, the municipality of Campo Grande had an estimated population of 914,000 inhabitants, with a geographic area of 8,092.95 km², and is geographically located in the central portion of the state, occupying 2.2% of the state’s total area. The municipality is organized into 7 Health Districts, called Anhanduizinho, Bandeira, Centro, Imbirussu, Lagoa, Prosa, and Segredo. PRMFC and PRMSF are part of the FHTs in 12 FHUs in the municipality.
From the implementation of the INOVAAPS Project in nine FHUs in 2020, and with the expansion to 12 Units in 2022 by the TEIAS project, it can be said that the offer of services to users was expanded, with the PHC fulfilling its roles of problem-solving and coordination of care.
The production data presented in this study compare the evolution of services with the period prior to the Project, given that, during this period of analysis, there was a considerable increase in the number of services in all areas. It is important to mention the variations in the exchange of groups of residents, in addition to the seasonality of the profile of care due to the COVID-19 pandemic in Brazil and the displacement of medical and multidisciplinary residents to provide care in other fields of the health service network, such as the Service Center for patients due to the COVID-19 pandemic, the Emergency Care Units (Unidades de Pronto Atendimento - UPAs), the Regional Health Centers (Centros Regionais de Saúde - CRSs) and the Vaccination Drives, given the need for management during the most critical period in the recent history of humanity in the field of Health.
Individualized procedures, when compared to data obtained from 2019 to 2023, showed an increase of approximately 86%, with this indicator considering the performance of procedures and/or minor surgeries, rapid tests, the administration of medications, as well as others procedures considered in the SUS Table of Procedures, Medications, and OPM Management System table (SIGTAP table).
Ahead, in Graph 1, the results and evolution of individualized procedures carried out in the nine FHUs linked to the TEIAS Project are demonstrated, covering health teams assigned to the PRMSF and PRMFC, from 2019 to December 2023.
Evolution of the number of individualized procedures of the Family Health Units (FHUs) assigned to PRMSF and PRMFC.
Medical care, during the analysis period, showed an increase of 81% in the absolute values of these services, when compared to the total number of services in these units from 2019 to December 2023, despite the events to combat the COVID-19 pandemic. These events brought about the need for health professional teams in other work scenarios, such as in COVID care centers and UPAs, as described in Graph 2.
Evolution of the number of medical procedures of the Family Health Units (FHUs) assigned to PRMSF and PRMFC.
The results of the growth in the percentage of procedures performed by the FHUs assigned to the TEIAS Project included the expansion of the portfolio of services offered in residential units, which showed more procedures performed by the medical team, such as: minor surgeries, canthoplasties, insertions of intrauterine devices, abscess drainage, sutures, synovial cavity infiltration, cerumen removal, among others. These results can also be seen in the empowerment of professional nurses, especially with regard to nursing consultations, consultation sharing, and insertions of intrauterine devices, as well as the categories of pharmacy and dentistry, which, during the pandemic, contributed to vaccine drives and rapid tests. This context was continued even after the pandemic had ended and can still be implemented when the attributes of access to and longitudinality of care, comprehensiveness of actions, coordination of care, and family and community guidance are not interrupted. Finally, positive results can also be seen in the structure of the services in basic models concerning medical care provided to the individual and the work process of the FHT, which is integrated and shared in the teaching service provided to the community14-16.
A comprehensive territory with a high burden of disease and social vulnerability are characteristics observed in our program as well as in residency programs offered by municipalities, demanding continuous challenges and constant work with qualified preceptors committed to provide training focused on the needs of SUS. The formulation must be permanent, through active work, and must focus on the multidisciplinarity and formative interdisciplinarity of the teaching process16-18.
In this sense, with the greater supply of procedures in these FHUs due to the expansion of the service portfolio and the qualification of records in the current information systems, better results were identified in the units when compared to previous years.
In the period prior to the implementation of the INOVAAPS project, there were few records of nursing consultations, since this professional category carried out its activities primarily through screening and risk classification. The significant increase in access to nursing consultations in the evaluated period, approximately 81% of outpatient care, is the result of an improved qualification of prenatal and child care, as well as of follow-up with patients from different lines of care and life cycles, with an important impact on embracement to spontaneous demand, as seen in Graph 3.
Evolution of the number of nursing procedures of the Family Health Units (FHUs) assigned to PRMSF and PRMFC.
A comprehensive territory with a high burden of disease and social vulnerability are characteristics observed in our program as well as in residency programs offered by municipalities, demanding continuous challenges and constant work with qualified preceptors committed to provide training focused on the needs of SUS. The formulation must be permanent, through active work, and must focus on the multidisciplinarity and formative interdisciplinarity of the teaching process16-18.
In this sense, with the greater supply of procedures in these FHUs due to the expansion of the service portfolio and the qualification of records in the current information systems, better results were identified in the units when compared to previous years.
In the period prior to the implementation of the INOVAAPS project, there were few records of nursing consultations, since this professional category carried out its activities primarily through screening and risk classification. The significant increase in access to nursing consultations in the evaluated period, approximately 81% of outpatient care, is the result of an improved qualification of prenatal and child care, as well as of follow-up with patients from different lines of care and life cycles, with an important impact on embracement to spontaneous demand, as seen in Graph 3.
The full resumption of outpatient care by dentists can be seen in mid-2022, which can also be evidenced by the increase in the amount of outpatient dental care provided. These results are clearly the result of a unified group of quality, training, and improvement work carried out together with preceptors, as well as the proportion of these with residents. Preceptors are able to guarantee a closer look at care and preceptorship techniques, be they shadow or minute preceptorship, and give residents the possibility of understanding the service with the support of their preceptor, whether from the center or in the field.
It is also possible to verify the significant increase in the provision of nursing care. These results can come from different situations, such as: the greater role of the nursing team in outpatient care and in coordinating care for users. We suggest that the increase in the amount of nursing care may also be related to the improvement in the quality of the record of care provided by professionals in the PEC e-SUS, as the performance of the resident’s teaching process is guided in this sense.
When we analyze the percentage of individualized procedures, medical care, nursing, and dental care, as described in Table 3, we observe that the greatest increases in percentage growth occurred from 2019 to 2020 for all procedures, with rates of 68.93%, 44.86%, and 64.17%, respectively, with the exception of dental procedures, which, in the same period, showed the lowest growth, with a rate of 0.79%; This low growth is justified by the pandemic period where dental procedures declined due to understandings related to biosafety and the use of personal protective equipment (PPE).
In relation to dental care, it is important to mention that this professional category suffered the greatest impact due to the COVID-19 pandemic, considering that it was the service that had the greatest restrictions for biosafety reasons. Even in this scenario, the TEIAS Project Units managed to expand access, increasing care by approximately 33% during the pandemic and, for 2023, an increase of 66% was identified, as compared to the same period of 2019, as can be seen in Graph 4.
Evolution of the number of dental procedures of the Family Health Units assigned to PRMSF and PRMFC.
However, as soon as the care protocols allowed the Dental Surgeon to work, growth in the evolution of dental care was observed, reaching a percentage of 66% when compared to the period from 2019 to December 2023. It was also noted that all individualized, medical, nursing, and dental procedures increased when the project began and compared to December 2023, at 86.94%, 81.97%, 81.80%, and 66%, respectively, bringing the prospect of increased growth year on year.
From the analysis of the data presented in Table 3, it is possible to verify the exponential increase in medical care, thus reinforcing the importance of qualifying professionals in the in-service teaching modality, as occurs in the form of residency programs linked to the TEIAS Project.
However, a service network with a greater number of graduates provides the user with a health professional capable of acting assertively and resolutely. As can be seen in Table 4, the absorption rate of doctors graduating from the TEIAS Project is 68% and 81%, for the first and second classes, respectively. For the group of multidisciplinary graduates from the first class, we obtained a rate of 43%, with rates found for those who graduated from the Teias Project reaching a rate above the observed average of 47.9% demonstrated in previous studies. This fact caused a positive impact on improvements in the offering of health services, the strengthening of PHC, and a higher quality of care provided to the population22,23.
Among the objectives of the PRMFC and PRMSF is the qualification of professionals so that the service offered to the population guarantees a welcoming, empathetic, human service, and presents, on the part of the user, greater satisfaction. Professionals who graduate from Residency Programs are trained and qualified to develop work that encompasses the principles and guidelines of SUS. However, the service needs to offer possibilities for this graduate to enter the Health System. In this sense, we carried out a search in the National Registry of Health Establishments (Cadastro Nacional de Estabelecimentos de Saúde - CNES) database, focused on the professional profile, in order to verify the absorption of graduates from PRMSF and PRMFC. Of the total number of PRMFC graduates, we obtained a total absorption rate, in APS, of 68% and 81% of the first and second classes, respectively. With regard to PRMSF graduates, the total absorption rate was 48% and 23% for the first and second classes, respectively, as shown in Table 4.
Preceptors who work in programs belonging to the TEIAS Project receive scholarships with a different value when compared to other programs in Brazil. Such incentives provide a greater retention of professionals, as well as make it possible to maintain a preceptor/resident ratio below that recommended by current legislation. Today, there is a ratio of 2.02 and 2.28 residents per preceptor, for the PRMFC and PRMSF, respectively. It is important to mention that, according to current regulations that deal with recommendations for the quality of residency programs, the ideal proportion is one 40-hour preceptor for up to 3 residents at PRMFC and one 40-hour preceptor for up to 5 residents at PRMSF, as can be seen in Table 5 15-17.
The in-service teaching process resulting from the expansion of teams by PRMFC and PRMSF brought numerous advances to PHC in the municipality of Campo Grande, guaranteeing patients comprehensive care for their demands, in turn strengthening the bond and longitudinality of care, and, consequently, reducing the number of referrals of sensitive care conditions to PHC, supporting the organization of the health service network.
Final considerations
Medical residency and multidisciplinary residency programs have proven to be a great dimension for the healthcare network, as they serve as an example within both the municipality itself and for other locations. The premise of working together with the medical residency and the multidisciplinary residency in an integrated format, in its own teams, in more vulnerable territories, and with the presence of active preceptorships in a proportional number, highlights a context of expanded care that often supports the entire care management policy in the municipality in which the residency is present and is in line with the TEIAS Project.
The perception of the constant evolution and increasing contribution of more qualified teams with professionals who are members and come from Residency Programs has proven to be an assertive concept for management to achieve health indicators and qualify access.
References
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Publication Dates
-
Publication in this collection
21 Oct 2024 -
Date of issue
Nov 2024
History
-
Received
10 Mar 2024 -
Accepted
13 May 2024 -
Published
15 May 2024
Source: Authors, based on e-Gestor AB Platform - data extracted in December 2022.
Source: Authors, based on e-Gestor AB Platform - data extracted in December 2023.
Source: Authors, based on e-Gestor AB Platform - data extracted in December 2023.
Source: Authors, based on e-Gestor AB Platform - data extracted in December 2023.