Meeting between EqSF and Nasf |
Discuss and analyze the cases of individuals and families who are accompanied at the Family Health Unit (FHU) and who require intervention from the EqSF and Nasf team or need to be referenced to the specialized network. At these meetings, unique therapeutic projects, collective action planning and discussion of clinical issues are built according to the need of the EqSF. |
EqSF and Nasf team and, eventually, trainees and residents, territory manager and other professionals working in the network of health services, education and social assistance. |
Monthly. |
Technical meetings between Nasf teams |
Promote integration between the Nasf teams and their coordination, giving priority to dialogue, exchange of experiences and reflection on the organization and development of the work process in the territory with the EqSF, as well as the construction of ways to evaluate and monitor actions. |
All the professionals that make up the Nasf teams, the territory managers and Nasf Coordination. |
Monthly. |
Meetings for articulation of the service network |
Strengthen the communication between the services with the aim of aligning the care to the user in an organized way within the care network. At these meetings, there are discussions about the flow of care, discussion of the more complex cases identified by the EqSF and the Nasf team or by reference services. |
Professionals who make up Nasf teams and representatives of the other services of the health network and assistance of the municipality, i.e. Psychosocial Care Center, Municipal Rehabilitation Center, Social Assistance Reference Center, etc. |
Monthly. |
Attendance at FHU |
Provide individual or shared care for evaluation, educational guidance and therapy. This care cannot be characterized as outpatient. Cases that require systematic care should be referenced for specialized services. |
Users needing individualized or shared care, identified from the meetings of the team. |
Monthly, and may vary according to the demand of each EqSF. |
Home visit |
Individual and/or shared visit for evaluation, educational and therapeutic guidance to the family and/or caregiver. Cases that require systematic care should be referenced for specialized services. |
Users in need of socioeconomic evaluation or assistance, identified from the meetings of the team, who are bedridden or unable to travel to the FHU. |
Variable. According to the demand of each EqSF. |
Health and/or Therapeutic Education Groups |
Perform collective activities with educational or therapeutic focus. These activities can be performed with programmatic groups of EqSF (Hiperdia, pregnant, adolescents, etc.) or groups created from the epidemiological profile of the territory (postural education, community therapy, benzodiazepine dependents, nutritional disorders, etc.). These groups can be held at the headquarters of the FHU or social facilities. |
Population attached to EqSF. |
Variable. According to the demand of each EqSF. |