ABSTRACT

This article aims to evaluate the clinical-care resolution capacity of multiprofessional teams in a municipality in the Northeast Region of Brazil. The concept of resolution capacity relates to the positive impact on users’ quality of life and considers functionality and contextual factors in their development. It is quantitative research with an evaluative and longitudinal approach. There was a follow-up of users assisted in a priority way, with shared follow-up among professionals from multidisciplinary teams and the Family Health Strategy (ESF). The clinical evolution of the users was performed using the Evaluation and Monitoring Form of the Clinical-Care Resolution Capacity of the Family Health Support Center (RCaNASF). The results are presented in two sections: the first one discusses the profile of the research subjects, considering their sociodemographic and clinical aspects, essential elements for understanding the healthcare work of multiprofessional teams; and the second discusses the resolution capacity of these teams in promoting the quality of life of users in primary health care. The conclusion suggests using RCaNASF to monitor the cases discussed between multidisciplinary and Family Health teams, enriching the workflow and health evaluation practices.

KEYWORDS
Primary Health Care; Outcome and process assessment, health care; Patient care team; Family health; Unified Health System

Introduction

In 2008, the Brazilian Ministry of Health (MS) created the Family Health Support Center (NASF) to enhance the effectiveness and comprehensiveness of Primary Health Care (PHC) in Brazil. Implemented through the creation of multiprofessional teams, the NASF has been set up in various municipalities across the country, undergoing multiple changes over time: in 2017 its name was changed¹1 Melo EA, Mendonça MHM, Oliveira JR, et al. Mudanças na Política Nacional de Atenção Básica: entre retrocessos e desafios. Saúde debate. 2018;42(esp1):38-51. DOI: https://doi.org/10.1590/0103-11042018S103
https://doi.org/10.1590/0103-11042018S10... , to Expanded Family Health Center (NASF-AB); in 2019 it faced the threat of extinction due to a new PHC funding model that withdrew specific resources for its maintenance²2 Ministério da Saúde (BR). Portaria nº 2.979, de 12 de novembro de 2019. Institui o Programa Previne Brasil, que estabelece novo modelo de financiamento de custeio da Atenção Primária à Saúde no âmbito do Sistema Único de Saúde, por meio da alteração da Portaria de Consolidação nº 6/GM/MS, de 28 de setembro de 2017. Diário Oficial da União, Brasília, DF. 2019 nov 13; Edição 220; Seção I:97-99.; and in 2023, the Ministry resumed efforts to strengthen an expanded PHC, issuing an ordinance³3 Ministério da Saúde (BR). Portaria GM/MS nº 635, de 22 de maio de 2023. Institui, define e cria incentivo financeiro federal de implantação, custeio e desempenho para as modalidades de equipes multiprofissionais na atenção primária à saúde. Diário Oficial da União, Brasília, DF. 23 maio 2023; Edição 96-B; Seção I-Extra-B:11-13. to reinstate funding for multidisciplinary teams to provide collaborative and complementary healthcare with primary care of NASF teams, now known as Multiprofessional teams (eMulti).

It is noteworthy that in some municipalities, the NASF teams were maintained with municipal funding, adopting the new eMulti designation in 2023. Although the ordinances that created these teams (NASF and eMulti) share many similarities, some significant changes were introduced with Ordinance No. 635 of May 23, 2023³3 Ministério da Saúde (BR). Portaria GM/MS nº 635, de 22 de maio de 2023. Institui, define e cria incentivo financeiro federal de implantação, custeio e desempenho para as modalidades de equipes multiprofissionais na atenção primária à saúde. Diário Oficial da União, Brasília, DF. 23 maio 2023; Edição 96-B; Seção I-Extra-B:11-13.. These include the expansion of professional categories eligible to be part of the teams, the return of more robust funding, the definition of other types of work teams, and the inclusion of new activities. Each of these changes may influence the groups’ workflow and should be closely monitored and studied in greater depth to support improvements in the teams’ workflow to strengthen interprofessional collaboration, comprehensiveness, and effectiveness of care in PHC.

Bispo Júnior and Almeida⁴4 Bispo Júnior JP, Almeida ER. Equipes multiprofissionais (eMulti): potencialidades e desafios para a ampliação da atenção primária à saúde no Brasil. Cad Saúde Pública. 2023;39(10):e00120123. DOI: https://doi.org/10.1590/0102-311XPT120123
https://doi.org/10.1590/0102-311XPT12012... point out that eMulti offers a wide range of activities, including individual and group healthcare, home assistance, shared consultations, case discussions, therapeutic projects, collective activities, matrix support, territorial interventions, remote healthcare, and intersectoral practices. When well-organized and effectively delivered, these activities have the potential to significantly enhance the problem-solving capacity of Primary Health Care (APS), as required by the regulations.

Since the creation of the Unified Health System (SUS), Brazil has undergone various reforms and policy shifts, with legal changes and new deliberations, intending to transform PHC through the Brazilian Family Health Strategy (ESF). The Family Health Support Center Team (EqNASF) consisted of the inclusion of new professional categories in PHC, to support the Family Health Teams (EqSF) in attempting to achieve comprehensive and effective healthcare for users, ultimately enhancing the quality of care in PHC⁵5 Iacabo P, Furtado JP. Núcleos de Apoio à Saúde da Família: análises estratégica e lógica. Saúde debate. 2020;44(126):666-677. DOI: https://doi.org/10.1590/0103-1104202012606
https://doi.org/10.1590/0103-11042020126... .

The concept of comprehensiveness considers that health-related actions should be implemented at both individual and collective levels, addressing the determining and conditioning factors of health. This includes integrating health promotion, prevention, and recovery activities through an interdisciplinary approach that incorporates the broader concept of health into practice⁶6 Albuquerque PC, Stotz EN. A educação popular na atenção básica à saúde no município: em busca da integralidade. Interface (Botucatu). 2004;8(15):259-274. DOI: https://doi.org/10.1590/S1414-32832004000200006
https://doi.org/10.1590/S1414-3283200400... and encourages public participation.

The theoretical-methodological framework of the interprofessional work process of the former EqNASF and the current eMulti uses matrix support as its central axis subdivided into technical-pedagogical and clinical-assistance support. From this perspective, specialized backup is requested to improve the quality of care for more complex clinical cases, which the EqSF could not resolve alone or would find very difficult to do so⁷7 Ministério da Saúde (BR), Departamento de Atenção Básica. Diretrizes do NASF: Núcleo de Apoio à Saúde da Família. Brasília, DF: Ministério da Saúde; 2010.. This theoretical framework of matrix support remains the basis for current eMulti.

The interprofessional work proposed to guide the work of these teams is positioned as strategic for confronting the traditional biomedical, curative, and highly fragmented healthcare model. By creating a ‘caring collective’, this approach enables support, sharing, and transformation of actions, carried out in a multi-professional way, seeking to meet the real needs of users and increase the effectiveness of care⁸8 Oliveira KSD, Baduy RS, Melchior R. O encontro entre o Núcleo de Apoio à Saúde da Família e as equipes de Saúde da Família: a produção de um coletivo cuidador. Physis. 2019;29(4):e290403. DOI: https://doi.org/10.1590/S0103-73312019290403
https://doi.org/10.1590/S0103-7331201929... .

Throughout the existence of the NASF many studies have been conducted to understand the work process of these teams. These studies have highlighted the complexity of their knowledge and actions, as well as the need to evaluate their outcomes from a perspective that recognizes not only the absence of disease but also the quality of life of users.

Thus, this study uses the concept of resolution capacity as the positive impact on users’ quality of life (QoL), focusing on addressing their health needs. It emphasizes the importance of comprehensiveness in healthcare practices, encompassing everything from health promotion and maintenance to rehabilitation, with the aim of a satisfactory response, which includes relieving or minimizing suffering⁹9 Rosa RB, Pelegrini AHW, Lima MAD. Resolutividade da assistência e satisfação de usuários da Estratégia Saúde da Família. Rev Gaúcha Enferm. 2011;32(2):345-351. DOI: https://doi.org/10.1590/S1983-14472011000200019
https://doi.org/10.1590/S1983-1447201100... .

It is worth emphasizing the importance of evaluating the results of actions to help managers and teams in planning, monitoring, and guiding healthcare practices. Therefore, the use and improvement of evaluation tools in the workplace should be encouraged, enabling the institutionalization of healthcare evaluation, which is often neglected in services¹⁰10 Nicola T, Pelegrini AHW. Avaliação em Saúde nos serviços de Atenção Primária no Brasil: uma revisão integrativa da literatura. J Nurs Health. 2018;8(1):e188102. DOI: https://doi.org/10.15210/jonah.v8i1.11091
https://doi.org/10.15210/jonah.v8i1.1109... .

This study aimed to evaluate the clinicalcare resolution capacity of eMulti in a municipality in the Northeastern region of Brazil.

Material and methods

This is an evaluative, quantitative, longitudinal study with an analysis of effects, conducted in a municipality in the metropolitan region of Recife, Pernambuco (PE), in the Northeast region of Brazil, from January to October 2019¹¹11 Damascena CG. Avaliação da resolutividade clínico-assistencial dos núcleos de apoio à saúde da família no município de Jaboatão dos Guararapes-PE [dissertação]. Recife: Instituto Aggeu Magalhães, Fundação Oswaldo Cruz; 2020. 109 p..

This research followed a series of studies. The first one, conducted by Nascimento12, investigated the organization of the NASF work process in three municipalities in Pernambuco. Subsequently, Sousa¹³13 Sousa FOS. Núcleo de Apoio à Saúde da Família: uma avaliação da integralidade, resolutividade e coordenação do cuidado [tese]. Recife: Centro de Pesquisas Aggeu Magalhães, Fundação Oswaldo Cruz; 2016. 155 p. focused on professionals’ perceptions of comprehensiveness, the expansion of resolution capacity, and the development of healthcare coordination in PHC. The third study was a thesis that developed and validated the content of a measuring instrument for evaluating and monitoring clinical-assistance care resolution¹⁴14 Cabral DL. Resolutividade clínico-assistencial do Núcleo de Apoio à Saúde da Família: construção de um instrumento de medida para avaliação e monitoramento [tese]. Recife: Instituto Aggeu Magalhães, Fundação Oswaldo Cruz; 2017. 154 p., the Evaluation and Monitoring Form of Clinical-Care Resolution Capacity of the Family Health Support Center (RCaNASF).

The sample was comprised of: a) professionals working in the eMulti teams (at the time of research, referred to as EqNASF) in the studied municipality, which covers seven health regions; all professionals in the teams with public employment ties through a competitive examination; those actively working during the data collection; and also those who participated in the matrix-based workshop to apply the data collection instrument. Users registered in the Family Health Units (USF) were also included; considered to be a priority for follow-up by eMulti teams and required care from at least two professionals from these teams and one from the EqSF¹⁴14 Cabral DL. Resolutividade clínico-assistencial do Núcleo de Apoio à Saúde da Família: construção de um instrumento de medida para avaliação e monitoramento [tese]. Recife: Instituto Aggeu Magalhães, Fundação Oswaldo Cruz; 2017. 154 p., regardless of whether they were part of a Singular Therapeutic Project.

Professionals who had been away from service for more than three months or those who could not submit the completed evaluation instrument by the end of the collection period were excluded, as were users who gave up participating in the study, without harming their clinical care.

Initially, the eMulti teams were made aware of the research by a video invitation and a summary of the project highlighting the importance of evaluating and monitoring the results of the actions. Afterward, the teams were trained on the new instrument through workshops held in each health region’s territory¹¹11 Damascena CG. Avaliação da resolutividade clínico-assistencial dos núcleos de apoio à saúde da família no município de Jaboatão dos Guararapes-PE [dissertação]. Recife: Instituto Aggeu Magalhães, Fundação Oswaldo Cruz; 2020. 109 p..

A field diary was also used. This instrument allows for immersion in recording everyday experiences and situations with critical observation, enabling evaluations and transformations¹⁵15 Kroeff RFS, Gavillon PQ. Ramm LV. Diário de campo e a relação do(a) pesquisador(a) com o campo-tema na pesquisa-intervenção. Estud Pesqui Psicol. 2020;20(20):464-480. DOI: https://www.e-publicaçoes.uerj.br/revispsi/article/view/52579
https://www.e-publicaçoes.uerj.br/revisp... . The facilitating and hindering aspects of the interprofessional work process were documented and presented in four categories: the relationship between professionals; transportation; materials/physical structures; and training/qualification for working in the EqNASF¹¹11 Damascena CG. Avaliação da resolutividade clínico-assistencial dos núcleos de apoio à saúde da família no município de Jaboatão dos Guararapes-PE [dissertação]. Recife: Instituto Aggeu Magalhães, Fundação Oswaldo Cruz; 2020. 109 p..

The associated EqSFs identified the health needs of people considered priority cases for follow-up by the EqNASF. Based on this screening, data collection was initiated. To facilitate the completion of the RCaNASF form, tutorial videos were produced and made available to the participating teams¹¹11 Damascena CG. Avaliação da resolutividade clínico-assistencial dos núcleos de apoio à saúde da família no município de Jaboatão dos Guararapes-PE [dissertação]. Recife: Instituto Aggeu Magalhães, Fundação Oswaldo Cruz; 2020. 109 p..

To understand the profile of the participating professionals, a semi-structured questionnaire was created and applied individually. This questionnaire gathered information on their gender, length of service in the studied municipality, professional category, and postgraduate education in Public Health or other specializations. Additionally, data on the individuals monitored by the EqNASF teams were collected using the RCaNASF to identify details such as gender, age, education level, diagnosed diseases or health conditions, medication use, and clinical progress over time¹⁴14 Cabral DL. Resolutividade clínico-assistencial do Núcleo de Apoio à Saúde da Família: construção de um instrumento de medida para avaliação e monitoramento [tese]. Recife: Instituto Aggeu Magalhães, Fundação Oswaldo Cruz; 2017. 154 p..

In this form, three clinical evaluations are recorded longitudinally with a minimum interval of one month between each evaluation, which can be monthly, bimonthly, or quarterly, depending on the user’s needs. The instrument is divided into two sections: functionality and contextual factors. For the functionality assessment, any impairments or difficulties observed during the evaluations should be rated as mild, moderate, severe, or very severe/total, based on the perspective of the healthcare professionals and the user, family member, or caregiver¹⁴14 Cabral DL. Resolutividade clínico-assistencial do Núcleo de Apoio à Saúde da Família: construção de um instrumento de medida para avaliação e monitoramento [tese]. Recife: Instituto Aggeu Magalhães, Fundação Oswaldo Cruz; 2017. 154 p..

In the functionality section, Part 1, there are two components: ‘Body Functions and Structures’ (FE) and ‘Activities and Participation’ (AP). The measurement of functionality is based on the International Classification of Functioning, Disability, and Health (ICF). FE refers to physiological functions and anatomical parts of the body, while AP relates to the performance of tasks and the individual’s involvement in life situations. In the contextual factors section, Part 2, there is the ‘Social, Family, and Individual Aspects’ (SFI) component. This refers to the physical and social environment in which the individual lives and interacts with others and the individual’s details such as age, emotional state, etc., which can positively or negatively impact their health condition¹⁴14 Cabral DL. Resolutividade clínico-assistencial do Núcleo de Apoio à Saúde da Família: construção de um instrumento de medida para avaliação e monitoramento [tese]. Recife: Instituto Aggeu Magalhães, Fundação Oswaldo Cruz; 2017. 154 p..

Comparing data from the first and last evaluations allows for an inference about the resolution capacity of NASF’s actions in improving the quality of life of users¹⁴14 Cabral DL. Resolutividade clínico-assistencial do Núcleo de Apoio à Saúde da Família: construção de um instrumento de medida para avaliação e monitoramento [tese]. Recife: Instituto Aggeu Magalhães, Fundação Oswaldo Cruz; 2017. 154 p.. Although the second evaluation is not used for the comparative calculation, this measure is important for monitoring the data as it may reveal whether the proposed intervention needs any modification or adjustment and whether any external factor positively or negatively affects the health-disease process of the evaluated person¹¹11 Damascena CG. Avaliação da resolutividade clínico-assistencial dos núcleos de apoio à saúde da família no município de Jaboatão dos Guararapes-PE [dissertação]. Recife: Instituto Aggeu Magalhães, Fundação Oswaldo Cruz; 2020. 109 p..

The software used for data processing was Excel^® 2010 and the Statistical Package for Social Sciences for Windows^® (SPSS), version 20¹⁶16 IBM Corp. IBM SPSS Statistics for Windows, Version 20.0. Armonk (NY): IBM Corp; 2011. IBM Corp. IBM SPSS Statistics for Windows [Internet]. Versão 20.0. Armonk (NY): IBM Corp; 2011 [acesso em 2019 jan 11]. Disponível em: https://www.ibm.com/products/spss-statistics
https://www.ibm.com/products/spss-statis... . In all statistical calculations, a 95% confidence level was used. To infer the clinicalassistance resolution of the studied teams, a comparison between the 1^st and 3^rd evaluations was conducted in the FE, AP, and SFI components of RCaNASF, from the perspective of the healthcare professionals and the user, family member, or caregiver. The paired t-test¹⁶16 IBM Corp. IBM SPSS Statistics for Windows, Version 20.0. Armonk (NY): IBM Corp; 2011. IBM Corp. IBM SPSS Statistics for Windows [Internet]. Versão 20.0. Armonk (NY): IBM Corp; 2011 [acesso em 2019 jan 11]. Disponível em: https://www.ibm.com/products/spss-statistics
https://www.ibm.com/products/spss-statis... and the Wilcoxon Signed Ranks test were used in the comparative analysis¹⁷17 Couch S, Kazan Z, Shi K, et al. A differentially private Wilcoxon signed-rank test. arXiv [cs.CR]. Reed College Mathematics Department; 2018; arXiv:1809.01635v1. DOI: https://doi.org/10.48550/arXiv.1809.01635
https://doi.org/10.48550/arXiv.1809.0163... .

The project that originated the study was approved by the Research Ethics Committee of the Oswaldo Cruz Foundation (FIOCRUZ Pernambuco), in compliance with the ethical principles of the National Health Council¹⁸18 Ministério da Saúde (BR); Conselho Nacional de Saúde. Resolução nº 466, de 12 de dezembro de 2012. Aprova as diretrizes e normas regulamentadoras de pesquisas envolvendo seres humanos e revoga as Resoluções CNS nos 196/96, 303/2000 e 404/2008. Diário Oficial da União, Brasília, DF. 2012 dez 13; Seção I:59-62.. It is registered on Plataforma Brasil under the Certificate of Presentation for Ethical Consideration (CAAE) No. 53408516.1.0000.5190, Opinion No. 3.143.672¹¹11 Damascena CG. Avaliação da resolutividade clínico-assistencial dos núcleos de apoio à saúde da família no município de Jaboatão dos Guararapes-PE [dissertação]. Recife: Instituto Aggeu Magalhães, Fundação Oswaldo Cruz; 2020. 109 p.. All participants were informed of the study’s objectives and signed the Free and Informed Consent Form.

Results and discussion

Between caregivers and healthcare: clinical-care profile of research subjects

According to the inclusion criteria, 51 potentially eligible users were selected for the study. However, during the data collection period, there was a sample loss of 20.0% (10.2): three declined to participate, four passed away before completing the data collection period, and three did not complete the last assessment. Consequently, the final sample consisted of 41 individuals monitored by EqNASF professionals and assessed using the RCaNASF instrument at three different moments¹¹11 Damascena CG. Avaliação da resolutividade clínico-assistencial dos núcleos de apoio à saúde da família no município de Jaboatão dos Guararapes-PE [dissertação]. Recife: Instituto Aggeu Magalhães, Fundação Oswaldo Cruz; 2020. 109 p., totaling 123 clinical evaluations. As table 1 shows, 53.6% (22) of those assessed were female, 46.4% (19) were elderly, and 51.0% (21) had not completed elementary school.

In 2019, the studied municipality had eight EqNASF teams, totaling 44 professionals. The smallest group consisted of four specialists, while the largest had seven. All specialists were invited to participate in this study; however, two groups did not meet the eligibility criteria. Therefore, six EqNASF groups participated in the investigation, totaling 28 specialists, including four social workers, four physiotherapists, three speech therapists, four nutritionists, four physical education professionals, three psychologists, and six occupational therapists. Of these, 93.0% (26) were female, with an average age of 34 years. Additionally, 29.0% (eight) had specialization in public health and related fields, 29.0% (eight) held a master’s degree, and another 29.0% (eight) were specialists in specific clinical areas.

In the field diary, all professionals reported on the facilitating and hindering aspects of the work process of the EqNASF teams¹¹11 Damascena CG. Avaliação da resolutividade clínico-assistencial dos núcleos de apoio à saúde da família no município de Jaboatão dos Guararapes-PE [dissertação]. Recife: Instituto Aggeu Magalhães, Fundação Oswaldo Cruz; 2020. 109 p.. As for the facilitating ones, 93.0% (26) stated that there was a good relationship among team members, and 71.4% (20) mentioned that their training and qualifications were important for their professional performance.

As the hindering aspect, the material/ physical infrastructures were considered precarious by 100.0% (28) of the professionals. Transportation was also considered poor by 71.4% (20) of the respondents, meaning that there was a lack of availability to carry out their work. This contrasts with another study that analyzed data from the evaluation of the Primary Care Access and Quality Improvement Program (PMAQ-AB), which indicated that vehicles were always or often available for such functions³⁰30 Brocardo D, Andrade CLT, Fausto MCR, et al. Núcleo de Apoio à Saúde da Família (Nasf ): panorama nacional a partir de dados do PMAQ. Saúde debate. 2018;42(esp1):130-144. DOI: https://doi.org/10.1590/0103-11042018S109
https://doi.org/10.1590/0103-11042018S10... .

This contradiction indicated that there are several realities in the country when it comes to the eMulti workflows. Fischborn and Cadoná³¹31 Fischborn AF, Cadoná MA. Trabalho e autonomia dos trabalhadores em saúde: considerações sobre pressupostos teórico e metodológicos de análise do trabalho em saúde. Saude Soc. 2018;27(1):227-237. DOI: https://doi.org/10.1590/S0104-12902018170719
https://doi.org/10.1590/S0104-1290201817... pointed out that one cannot relativize or overlook the work conditions in the context of social and political relations so that there is autonomy for healthcare professionals.

Table 2 shows the professionals involved in the shared care of studied cases. In the EqNASF teams, occupational therapists worked in 76.0% (31) of the cases, and physiotherapists in 41.5% (17) of them. Among the EqSF professionals who shared care with specialists, nurses were the second most involved professional category, participating in 63.4% (26) of the cases.

The high demand for clinical follow-ups involving occupational therapists in this study reflects several observations recorded in the field diary. The process of applying the RCaNASF instrument was facilitated by the daily work practice of this professional category in conducting a comprehensive assessment of the individual observing various components: mental, sensory, auditory, motor, social, and environmental, transiting through various areas of activity such as education, work, and health. This could indicate the need to strengthen the ongoing training of these teams with a focus on expanded clinical practices aiming at implementing increasingly comprehensive and collaborative healthcare practices.

Researchers³²32 Melo EA , Miranda L, Silva AM, et al. Dez anos dos Núcleos de Apoio à Saúde da Família (Nasf ): problematizando alguns desafios. Saúde debate. 2018;42(esp1):328-340. DOI: https://doi.org/10.1590/0103-11042018S122
https://doi.org/10.1590/0103-11042018S12... observed a critical issue in the effective implementation of shared interprofessional healthcare related to team management. The authors highlighted the presence of power dynamics that influence managerial issues, team composition, and schedule planning. Therefore, a significant effort is needed to organize the work process of EqNASF teams, as well as to remain open to changes, acting collaboratively with EqSF teams and other services in the healthcare network to achieve higher-quality care.

An article by Tavares³³33 Tavares TT, Brito GEG, Andrade AJB, et al. Avaliação do trabalho em equipe nos núcleos ampliados de saúde da família e atenção básica. OLEL. 2024;22(7):e5602. DOI: https://doi.org/10.55905/oelv22n7-037
https://doi.org/10.55905/oelv22n7-037... points out that EqNASF workers who were satisfied with the communication and the clear definition of responsibilities among team members were more likely to rate their work positively.

Mazza et al.³⁴34 Mazza DAA, Carvalho BG, Carvalho MN, et al. Aspectos macro e micropolíticos na organização do trabalho no NASF: o que a produção científica revela? Physis. 2020;30(4):e300405. DOI: https://doi.org/10.1590/S0103-73312020300405
https://doi.org/10.1590/S0103-7331202030... highlight issues linked to the influence of macroand micropolitical aspects on work organization, professional practice, and the integration of work between professionals in the matrix and reference teams. Collaboration demands a paradigm shift, replacing healthcare models that favor asymmetrical power relations and fragmented practices.

The resolution capacity of multiprofessional teams and the production of quality of life for users under their care

This article aimed to evaluate specific aspects of clinical-care actions, one of the dimensions of matrix support within the workflows of healthcare teams. This methodological choice uses the RCaNASF instrument, which focuses on this dimension but prioritizes a comprehensive and collaborative approach by professionals, valuing the life and illness processes and the user’s perspective. The RCaNASF was applied in situations where more than one profession had to work together, i.e. where the individual’s health condition required interprofessional monitoring.

Table 3 presents the progression of cases monitored by the studied EqNASF teams. A positive progression indicates perceived improvements in the user’s clinical and/or social condition over the three evaluations. On the other hand, maintenance reflects no change from the initial status, while negative progression suggests a decline or a perceived worsening. Discrepancies in some values between users and/or caregivers and healthcare professionals may be related to differences in their expectations of change.

In Part 1 of the RCaNASF, a positive progression was observed when comparing data from the first and last evaluations, especially in the FE component, both in the perception of professionals, in 80.4% (33) of cases, and in that of users, in 73.0% (30) of cases. This finding aligns with a doctoral thesis¹⁴14 Cabral DL. Resolutividade clínico-assistencial do Núcleo de Apoio à Saúde da Família: construção de um instrumento de medida para avaliação e monitoramento [tese]. Recife: Instituto Aggeu Magalhães, Fundação Oswaldo Cruz; 2017. 154 p., whose pilot study used the RCaNASF. In the AP component, this improvement was noted in 70.8% (29) of cases according to professionals, and in 58.5% (24) according to users.

The data produced in this study show that, in Part 2 of the RCaNASF, within the SFI component, there was a positive shift in aspects identified as hindrances to health conditions in the monitored clinical cases. This improvement was observed both in the perception of professionals, in 65.8% (27) of cases, and in that of users, in 58.5% (24) of the cases. A positive progression was also noted in aspects already considered facilitators, in 22.0% (9) and 14.6% (6) of cases, while maintenance was observed in 65.8% (27) and 70.8% (29) of cases, in the perception of professionals and users, respectively (table 3).

Facilitating or hindering factors are elements that can either support or undermine the functional performance or quality of life of the evaluated user¹⁴14 Cabral DL. Resolutividade clínico-assistencial do Núcleo de Apoio à Saúde da Família: construção de um instrumento de medida para avaliação e monitoramento [tese]. Recife: Instituto Aggeu Magalhães, Fundação Oswaldo Cruz; 2017. 154 p.. Therefore, a significant portion of the issues that were hindering patients’ lives showed improvement, while those that were already facilitating their condition remained stable, with some even showing further improvement.

Considering the concept of resolution capacity used in this study and adding the percentages of clinical progression – whether positive or stable – in both parts and across each component of the RCaNASF, the results show achievement rates of 85.4% or higher in meeting the intended objectives. This suggests a potential positive impact on the healthrelated quality of life of the individuals¹¹11 Damascena CG. Avaliação da resolutividade clínico-assistencial dos núcleos de apoio à saúde da família no município de Jaboatão dos Guararapes-PE [dissertação]. Recife: Instituto Aggeu Magalhães, Fundação Oswaldo Cruz; 2020. 109 p..

In each of the three components, there was a small percentage of negative evolution, less than 17.1% of cases. This finding reflects the medical conditions of the individuals monitored in this study, as exacerbations can occur in non-communicable chronic diseases (NCDs). In the case of hypertension (SAH), risk factors such as diabetes, obesity, dyslipidemia, sedentary behavior, smoking, and excessive alcohol consumption can worsen this condition²⁵25 Brandão AA, Nogueira AR. Manual de hipertensão arterial. Rio de Janeiro: Socerj; 2018. 108 p..

When analyzing table 4 and considering the concept of resolution capacity adopted in this study, a positive evolution is observed in the monitored cases. This is because the sum of the percentages for maintenance and improvement in the evaluated conditions, in each component, and for each EqNASF team, was equal to or greater than 60.0%¹¹11 Damascena CG. Avaliação da resolutividade clínico-assistencial dos núcleos de apoio à saúde da família no município de Jaboatão dos Guararapes-PE [dissertação]. Recife: Instituto Aggeu Magalhães, Fundação Oswaldo Cruz; 2020. 109 p..

These data are in line with a doctoral thesis¹³13 Sousa FOS. Núcleo de Apoio à Saúde da Família: uma avaliação da integralidade, resolutividade e coordenação do cuidado [tese]. Recife: Centro de Pesquisas Aggeu Magalhães, Fundação Oswaldo Cruz; 2016. 155 p., in which the EqNASF’s resolution capacity reached 60.0% in the psychology category, and percentages above 70.0% for other professional categories, showing an increase in PHC actions.

The negative evolution, represented by 40.0% in the AP – User component for Team 2 (table 4), was identified through database analysis. This result was due to two clinical cases: one in the field of mental health, involving difficulties in interaction and interpersonal relationships, along with worsening restrictions on community and social life. The other case involved sequelae from a traumatic injury with multiple pre-existing impairments that led to social isolation and limitations in the individuals’ leisure activities¹¹11 Damascena CG. Avaliação da resolutividade clínico-assistencial dos núcleos de apoio à saúde da família no município de Jaboatão dos Guararapes-PE [dissertação]. Recife: Instituto Aggeu Magalhães, Fundação Oswaldo Cruz; 2020. 109 p..

Another relevant observation is the negative evolution (33.3%) identified in two cases in Team 6, in the components AP – Professional, SFI (–) – Professional and User. The individuals being monitored faced multiple conditions: one with a degenerative disease and mental health disorders, and the other had rheumatic diseases, a disability, and mental health issues. These conditions indicate the need for prolonged follow-up to maximize the positive impact on their lives¹¹11 Damascena CG. Avaliação da resolutividade clínico-assistencial dos núcleos de apoio à saúde da família no município de Jaboatão dos Guararapes-PE [dissertação]. Recife: Instituto Aggeu Magalhães, Fundação Oswaldo Cruz; 2020. 109 p.. This point is relevant as it underscores the limitations of NASF’s multidisciplinary team (eMulti) and emphasizes the need for network-based interventions, integrating various PHC and specialized services. Additionally, it reinforces the importance of developing intersectoral actions to address the social determinants of health that directly affect the effectiveness of PHC care.

When analyzing resolution capacity based on the EqNASF teams’ profile, it is noted that Team 5 showed no negative evolution (table 4). A review of the database reveals that all professional categories were actively engaged in the cases and that this team’s members are trained in clinical areas, public health, and mental health¹¹11 Damascena CG. Avaliação da resolutividade clínico-assistencial dos núcleos de apoio à saúde da família no município de Jaboatão dos Guararapes-PE [dissertação]. Recife: Instituto Aggeu Magalhães, Fundação Oswaldo Cruz; 2020. 109 p..

From the sum of the scores obtained in the 1^st and 3^rd evaluations, the average for each component of the RCaNASF was calculated, along with the p-value, resulting in what is shown in table 5. The higher the average, the greater the number of subcategories scored or qualified in each component¹⁴14 Cabral DL. Resolutividade clínico-assistencial do Núcleo de Apoio à Saúde da Família: construção de um instrumento de medida para avaliação e monitoramento [tese]. Recife: Instituto Aggeu Magalhães, Fundação Oswaldo Cruz; 2017. 154 p.. The subcategories are evaluation elements that reveal impairment, difficulties, facilitators, and obstacles that interfere with the individual’s functionality.

Table 5 confirms that Part 1 of the instrument, covering the FE and AP components, and Part 2, focusing on the SFI (–) component, were the most evaluated – representing identified impairments and difficulties, as well as recognized barriers, respectively. When comparing the means of the 1^st and 3^rd evaluations, there was a statistically significant difference (p-value < 0.05), except for the SFI (+) component, a qualified facilitator, which obtained a p-value > 0.05 in both the professionals’ and users’ perceptions, supporting findings from a previous study¹⁴14 Cabral DL. Resolutividade clínico-assistencial do Núcleo de Apoio à Saúde da Família: construção de um instrumento de medida para avaliação e monitoramento [tese]. Recife: Instituto Aggeu Magalhães, Fundação Oswaldo Cruz; 2017. 154 p.. Upon analyzing the means of the 1^st and 3^rd evaluations in this component, the values remained the same, suggesting that the facilitating aspects in individuals’ lives stayed consistent, which, in a way, is positive for resolution capacity and the quality of lives¹¹11 Damascena CG. Avaliação da resolutividade clínico-assistencial dos núcleos de apoio à saúde da família no município de Jaboatão dos Guararapes-PE [dissertação]. Recife: Instituto Aggeu Magalhães, Fundação Oswaldo Cruz; 2020. 109 p..

Only one study¹⁴14 Cabral DL. Resolutividade clínico-assistencial do Núcleo de Apoio à Saúde da Família: construção de um instrumento de medida para avaliação e monitoramento [tese]. Recife: Instituto Aggeu Magalhães, Fundação Oswaldo Cruz; 2017. 154 p. is available to compare the quantitative data from this research with other studies using the same instrument, RCaNASF, emphasizing the need to expand the longitudinal evaluation of eMulti results to gather more robust evidence.

The RCaNASF can improve case discussions between EqNASF and EqSF by promoting comprehensive care for individuals. It involves identifying aspects of functionality and the life contexts, documenting difficulties and impairments mentioned by users, and incorporating evaluations from healthcare professionals assisting them. This process enables the mobilization of necessary resources for a more coherent intervention¹¹11 Damascena CG. Avaliação da resolutividade clínico-assistencial dos núcleos de apoio à saúde da família no município de Jaboatão dos Guararapes-PE [dissertação]. Recife: Instituto Aggeu Magalhães, Fundação Oswaldo Cruz; 2020. 109 p..

The instrument provides a comprehensive view of the user, including their concerns and health conditions, as well as the factors that facilitate or hinder their functional performance and quality of life¹⁴14 Cabral DL. Resolutividade clínico-assistencial do Núcleo de Apoio à Saúde da Família: construção de um instrumento de medida para avaliação e monitoramento [tese]. Recife: Instituto Aggeu Magalhães, Fundação Oswaldo Cruz; 2017. 154 p., while also tracking their progress over time. This can lead to the shared definition of goals and plans to specifically address current clinical and care processes¹¹11 Damascena CG. Avaliação da resolutividade clínico-assistencial dos núcleos de apoio à saúde da família no município de Jaboatão dos Guararapes-PE [dissertação]. Recife: Instituto Aggeu Magalhães, Fundação Oswaldo Cruz; 2020. 109 p..

Based on the collected information and continuous monitoring, managers and professionals can use the data to demonstrate the impact of the collaborative efforts between EqNASF and EqSF, and at the same time shedding light on the complexity of the health and disease conditions involved in their work.

In principle, the matrix support provided by EqNASF leads to improvements in the resolution capacity and comprehensiveness of PHC. However, gaps in monitoring may result in a lack of awareness of the factors influencing the effectiveness of these actions and the overall quality of healthcare³⁰30 Brocardo D, Andrade CLT, Fausto MCR, et al. Núcleo de Apoio à Saúde da Família (Nasf ): panorama nacional a partir de dados do PMAQ. Saúde debate. 2018;42(esp1):130-144. DOI: https://doi.org/10.1590/0103-11042018S109
https://doi.org/10.1590/0103-11042018S10... .

Final considerations

The findings reinforce that EqNASF’s interprofessional approach is a crucial strategy for enhancing the resolution capacity of PHC. An analysis of the RCaNASF data showed a positive and statistically significant difference in most evaluated components, indicating clinical improvement in individuals monitored by EqNASF, with a minimum resolution rate of 83.3%.

The users monitored in this study were primarily older individuals, women, and individuals with chronic conditions such as hypertension (SAH) and diabetes (DM), along with a high prevalence of mental health-related issues. As for the professionals in EqNASF, all categories were represented, with occupational therapists and physiotherapists playing a prominent role in most clinical follow-up requests, followed by nutritionists and social workers. It is important to note that the cases studied reflect the health needs of the population in the areas covered by EqSF, with support from EqNASF.

In the evaluation conducted by EqNASF, both the maintenance and positive progress in resolution rates reached a minimum of 60% for each component of the RCaNASF instrument. Notably, some EqNASF teams reported no cases of clinical deterioration, while others observed negative progress percentages ranging from 10% to 40%. This suggests that the outcomes of EqNASF’s clinical-care actions reflect a positive contribution by healthcare professionals in their respective fields, leading to improved resolution rates and a better quality of life for users being monitored.

The study recommends adopting RCaNASF for the matrix support in shared cases between EqNASF and EqSF, strengthening healthcare evaluation practices and enriching the overall work process. The systematic integration of this new tool into EqNASF’s interprofessional care routine took place throughout the research, facilitated by matrix support workshops and discussions during the follow-up of the evaluated individuals.

Considering these perspectives, and the absence of comparative data from longitudinal studies that show quantitative results regarding EqNASF’s resolution capacity rates, it is evident that expanding the documentation and evaluation of the work done by these teams is essential. Moreover, it is important to examine various contexts to strengthen the objectives outlined in the guidelines, to ensure quality and comprehensiveness in primary health care through the development of integrated actions that guarantee the effectiveness of healthcare practices.

References

Publication Dates

History