I. Territorialization and health responsibility |
Situational diagnosis |
Recognition of the determinants in the assigned territory as indicators and supporters of NASF-AB. |
Planning based on territory problems |
Care production considering the proposition, implementation, and evaluation plan of actions appropriate to the context, with elucidation of what is expected to be achieved, and involving social stakeholders. |
Management of risks, vulnerability, and collective potential |
Frequent mapping of the territory's health needs, incorporating technologies to manage recognized risks and vulnerabilities. |
Monitoring and evaluation of the work process |
Systematic monitoring of activities, use of recording tools, evaluation, readjustment and monitoring of actions considering the territory. |
II. Teamwork |
Articulated action with the eSF/eAB |
Practices alluding to teamwork, use of care strategies and adoption of shared agendas for planning and conducting actions dialogically and collectively. |
Matrix support in the technical-pedagogical and clinical-care dimensions of the eSF/eAB |
Incorporation of continuing education as an educational and transformative tool, and shared action, with the creation of collective spaces for discussion and intervention for users and professionals. |
Management of complex cases with the participation of eSF/eAB |
Discussion agendas for the shared elaboration of the PTS and evaluation of health care plans and monitoring of complex cases. |
III. Comprehensiveness |
Recognition of points of care networks |
Intersectoral actions and dialogical adoption of health care network flows suited to the needs of groups, in order to implement a shared responsibility. |
Development of intersectoral actions |
Establishment of links with the community and the other points of the care network to produce citizenship and spaces of social control. |
Assessment of complex cases and risk classification |
Discussion of cases, based on interprofessional dialogue, with risk classification and definition of flows that support forwarding and shared decision-making. |
IV. Individual and collective autonomy |
Reception and qualified listening to individuals and groups |
Establishment of reception with humane and qualified listening to individuals and communities, focusing on social or affective-cultural risk situations. |
Solidary and longitudinal links |
Active participation in community discussion spaces, encouraging participatory management, development of cultural, sports and income generation activities in the community. |
Encouraging individual and collective initiative in the production of care |
Development of actions for the production of care and health promotion through therapeutic practices of self-care and quality of life. |