Abstract

This study investigates the challenges and possibilities of health professionals in managing care for dependent older adults in PHC. We employed a qualitative approach based on dialectical hermeneutic fusion. Interviews were carried out with 38 health professionals, from June to December 2019, in eight cities in the five Brazilian regions, which resulted in themes about the challenges of professionals in the management of care for older adults, the strategies used, and their suggestions for improving the quality of care for dependent older adults. Management failures, structural factors, access barriers, scarce supplies, disrupted network, and lack of security, were pointed out as hardships in directing health protection, prevention, and promotion actions. The applied strategies are diverse and conflicting and aim to articulate the multiprofessional teams, which involve the Family Health Strategy and specialists to implement care. Strengthening reception, encouraging home consultation, mobilizing support groups, and carrying out health education were among the participants’ integrative practices. Due to the complex study object, it was evidenced that professionals recognize the shortcomings in the health services and face undesirable situations due to the lack of qualified personnel in the teams and the defective materials and transportation.

Key words:
Health care; Health personnel; Dependent older adults; Primary Health Care; Qualitative research

Introduction

Population aging is part of the demographic reality in Brazil and worldwide. The World Health Organization (WHO) warns that two billion older adults are expected in 2050, and, in the Americas, people over 60 will increase more than threefold in the next 30 years, up from eight to thirty million¹1 Organização Mundial da Saúde (OMS). Mundo terá 2 bilhões de idosos em 2050; OMS diz que 'envelhecer bem deve ser prioridade global'. Brasília: Organização Pan-Americana da Saúde; 2014 [acessado 2020 Abr 28]. Disponível em: https://nacoesunidas.org/mundo-tera-2-bilhoes-de-idosos-em-2050-oms-diz-que-envelhecer-bem-deve-ser-prioridade-global/^,22 Organização Mundial da Saúde (OMS). Número de pessoas idosas com necessidade de cuidados prolongados triplicará nas Américas até 2050. Brasília: Organização Pan-Americana da Saúde; 2019 [acessado 2020 Abr 28]. Disponível em: https://nacoesunidas.org/numero-de-pessoas-idosas-com-necessidade-de-cuidados-prolongados-triplicara-nas-americas-ate-2050. Brazil will be the sixth highest ranked country in older adults by 2025, reaching 22.71% of the total population in 2050.

Chronic health problems arise with age. They often lead older adults to become dependent on care and challenges from health systems that demand more resolute lines of care and care networks³3 Minayo MCS. O imperativo de cuidar da pessoa idosa dependente. Cien Saude Colet 2019; 24(1):247-252.. The World Health Organization (WHO) spearheads the Decade of Healthy Aging 2020-2030 to promote longevity and healthy lives, in line with the Sustainable Development Goals⁴4 Organização Pan-Americana da Saúde (OPAS). Agenda de saúde sustentável para as Américas 2018-2030: um chamado à ação para a saúde e o bem-estar na região [matéria na Internet]. Washington: OPAS; 2017 [acessado 2019 Fev 27]. Disponível em: https://www.paho.org/hq/index.php?option=com_docman&task=doc_download&gid =42117&Itemid=270&lang=pt. In parallel with aging is an urgent need to care for this population to prevent dementia and physical and mental disabilities⁵5 Campos ACV, Goncalves LHT. Perfil demográfico do envelhecimento nos municípios do Estado do Pará, Brasil. Rev Bras Enferm 2018; 71(Supl.1):591-598..

The Ministry of Health developed from 1994 to the present the National Policy for Older Adults⁶6 Brasil. Lei n. 8.842, de 4 de janeiro de 1994. Dispõe sobre a Política Nacional do Idoso, cria o Conselho Nacional do Idoso e dá outras providências. Diário Oficial da União 1994; 5 jan.. As of 2000, Policies have intensified - Statute for Older Adults⁷7 Brasil. Lei n. 10.741, de 1º de outubro de 2003. Dispõe sobre o Estatuto do Idoso e dá outras providências. Diário Oficial da União 2003; 3 out.; National Health Policy for Older Adults⁸8 Brasil. Ministério da Saúde (MS). Portaria n. 2.528, de 19 de outubro de 2006. Aprova a Política Nacional de Saúde da Pessoa Idosa. Diário Oficial da União 2006; 20 out.; Primary Care Policy⁹9 Brasil. Ministério da Saúde (MS). Portaria n. 648, de 28 de março de 2006. Dispõe sobre a aprovação da Política de Atenção Básica, estabelecendo diretrizes e normas para a organização da Atenção Básica para o Programa Saúde da Família (PSF) e o Programa de Agentes Comunitários de Saúde (PACS). Diário Oficial da União 2006; 29 mar.; Strategic Action Plan for Coping with Chronic Non-Communicable Diseases in the 2011-2022¹⁰10 Brasil. Ministério da Saúde (MS). Plano de ações estratégicas para o enfrentamento das doenças crônicas não transmissíveis (DCNT) no Brasil 2011-2022. Brasília: MS; 2011. period; National Active Aging¹¹11 Brasil. Decreto n. 8.114, de 30 de setembro de 2013. Estabelece o compromisso nacional para o envelhecimento ativo e institui comissão interministerial para monitorar e avaliar ações em seu âmbito e promover a articulação de órgãos e entidades públicos envolvidos em sua implementação. Diário Oficial da União 2013; 1 out. Policy; Guidelines for the Care of Older Adults in the Unified Health System (SUS); and Technical Guidelines for the Implementation of the Care Line for Comprehensive Health Care for Older Adults in the SUS¹²12 Brasil. Ministério da Saúde (MS). Orientações técnicas para a implementação de Linha de Cuidado para Atenção Integral à Saúde da Pessoa Idosa no Sistema Único de Saúde - SUS [livro na Internet]. Brasília: MS; 2018. [acessado 2020 Maio 05]. Disponível em: http://bvsms.saude.gov.br/bvs/publicacoes/linha_cuidado_atencao_pessoa_idosa.pdf.

The increased life expectancy and the fragmented care in the care networks for older adults are a reality that influences the system’s resolution and leaves dependent older adults receiving care at home unassisted. Depending on this fact, PAHO/WHO²2 Organização Mundial da Saúde (OMS). Número de pessoas idosas com necessidade de cuidados prolongados triplicará nas Américas até 2050. Brasília: Organização Pan-Americana da Saúde; 2019 [acessado 2020 Abr 28]. Disponível em: https://nacoesunidas.org/numero-de-pessoas-idosas-com-necessidade-de-cuidados-prolongados-triplicara-nas-americas-ate-2050 expresses that disability-associated aging has increased by 12.6% since 2009. PAHO’s Plan of Action on the Health of Older Persons, including Active and Healthy Aging for the period 2009-2018 report, showed that health workers are not prepared to meet the needs of older adults⁴4 Organização Pan-Americana da Saúde (OPAS). Agenda de saúde sustentável para as Américas 2018-2030: um chamado à ação para a saúde e o bem-estar na região [matéria na Internet]. Washington: OPAS; 2017 [acessado 2019 Fev 27]. Disponível em: https://www.paho.org/hq/index.php?option=com_docman&task=doc_download&gid =42117&Itemid=270&lang=pt.

Health care management must involve multiple dimensions, adjusting to each stage of life, searching for well-being, security, and autonomy, and can benefit from access to health resources available in the social environment¹³13 Cecilio LCO. Apontamentos teórico-conceituais sobre processos avaliativos considerando as múltiplas dimensões da gestão do cuidado em saúde. Interface (Botucatu) 2011; 15(37):598-599.. In the SUS organizational scope, PHC is the main gateway to the system, as it is where users’ first contact with health services and professionals should take place longitudinally, aiming at comprehensive care, focusing on prevention and health promotion actions¹⁴14 Schenker M, Costa DH. Avanços e desafios da atenção à saúde da população idosa com doenças crônicas na Atenção Primária à Saúde. Cien Saude Colet [periódico na Internet]. 2019 Abr [acessado 2020 Maio 17]; 24(4):1369-1380. Disponível em: https://www.scielo.br/pdf/csc/v24n4/1413-8123-csc-24-04-1369.pdf
https://www.scielo.br/pdf/csc/v24n4/1413... . In the reorientation of the PHC health care model, Family Health Strategy (ESF) leads the care to the family and the community¹⁴14 Schenker M, Costa DH. Avanços e desafios da atenção à saúde da população idosa com doenças crônicas na Atenção Primária à Saúde. Cien Saude Colet [periódico na Internet]. 2019 Abr [acessado 2020 Maio 17]; 24(4):1369-1380. Disponível em: https://www.scielo.br/pdf/csc/v24n4/1413-8123-csc-24-04-1369.pdf
https://www.scielo.br/pdf/csc/v24n4/1413... .

From the perspective of Oliveira et al.¹⁵15 Oliveira MR, Veras RP, Cordeiro HA. A importância da porta de entrada no sistema: o modelo integral de cuidado para o idoso. Physis [periódico na Internet]. 2019 [acessado 2020 Maio 05]; 28(4):e280411. Disponível em: https://www.scielo.br/pdf/physis/v28n4/0103-7331-physis-28-04-e280411.pdf
https://www.scielo.br/pdf/physis/v28n4/0... , the way of caring for older adults in Brazil, particularly dependent older adults, must be reworked to achieve a logical and coherent care path in the face of an articulated network of services and people. These transformations must be implemented in services, training of health professionals, support to the organization, and management of resources and financing.

However, it is necessary to clarify the strategies used to prevent risks and manage this population’s health conditions. Understanding the challenges of professionals who address the care of these dependent older adults within PHC daily and investigating their care strategies and the suggestions for improvements to support coping with health problems of this frail population can open new avenues and strengthen comprehensive care in the SUS. This study aimed to investigate the challenges and possibilities of health professionals for the management of care for dependent older adults in Primary Health Care.

Methods

This paper is nested in a multicenter study called Situational study of dependent older adults living with their families to subsidize care and support policy for caregivers, linked to the Jorge Careli Department of Violence and Health Studies, the Oswaldo Cruz Foundation.

A qualitative study was conducted from a hermeneutic-dialectic perspective, which anchors the comprehensive and critical processes of a social event¹⁶16 Habermas J, Redondo MJ. Teoría de la acción comunicativa. Madrid: Taurus; 1987.^,1717 Minayo MCS. O desafio do conhecimento: pesquisa qualitativa em saúde. 13ª ed. São Paulo: Hucitec; 2013.. Hermeneutics seeks to near the meaning established by professionals when they live the experience of caring for dependent older adults, emphasizing beliefs, values, objective actions, and subjective meanings. Dialectics allows confronting social components under critical lenses.

The study reported here was developed in eight municipalities in the five Brazilian regions, including Brasília, Teresina, Fortaleza, Manaus, Rio de Janeiro, and Belo Horizonte Porto Alegre, and Araranguá. These municipalities were chosen to understand the national realities due to the diverse and intricate aspects of social, cultural, and health conditions¹⁸18 Barreto ML. Desigualdades em Saúde: uma perspectiva global. Cien Saude Colet [periódico na Internet]. 2017 Julho [acessado 2020 Maio 21]; 22(7):2097-2108. Disponível em: https://www.scielo.br/pdf/csc/v22n7/1413-8123-csc-22-07-2097.pdf
https://www.scielo.br/pdf/csc/v22n7/1413... .

Thirty-eight PHC professionals who provided some care to dependent older adults were interviewed for this section of the study. Among the professional categories interviewed were doctors (8), nurses (18), psychologists (1), physiotherapists (1), social workers (3), dentists (2), biologists (1), physical educators (1), nursing technicians (1), pedagogues (1) and community health workers (1). Participants with at least one-year experience in PHC services were included to ensure the experience of caring for dependent older adults. Those who were on vacation or were removed for any reason from work activities were excluded.

Key informants from the municipal health departments indicated the participants, based on previous knowledge about the registration of households and UBS that attended older adults dependent on any type of physical, mental, or social care. The inclusion criteria considered health professionals who had worked, for at least a year, in PHC services and municipal programs that provided support to older adults and their families. The invited professionals were contacted in person, by phone, or social media. They received information about the study upon accepting the invitation.

Data were collected through semi-structured interviews to capture identification data, sociodemographic characteristics, facilities, and difficulties in receiving and monitoring the care of the dependent older adults and the support strategies used. Interviews were held from June to December 2019 after participants signed the Informed Consent Form (ICF), at reserved places in the respondent’s work environments, with a mean duration of 20 minutes.

The data were sorted, classified, and analyzed following the steps of transcribing the interviews, reading, rereading the material, and separating the sets of signs that emerged from the text (sorting); grouping the sets of signs and their analytical classification (classification), and interpretation of the data, bringing to the fore the complementarities, convergences, divergences, and the unusual, from the empirical universe¹⁷17 Minayo MCS. O desafio do conhecimento: pesquisa qualitativa em saúde. 13ª ed. São Paulo: Hucitec; 2013..

The research follows the dictates of Resolution 466/2012¹⁹19 Brasil. Conselho Nacional de Saúde (CNS). Resolução nº 466, de 12 de dezembro de 2012. Dispõe das normas para pesquisa envolvendo seres humanos. Diário Oficial União 2013; 13 jun., having been approved by the Research Ethics Committee of Oswaldo Cruz Foundation. The abbreviations of the professions, followed by the name of the city where the collection was carried out, were used to protect the identities of the participants.

Results

The results are presented in two themes that emerged from the collected empirical material. It is worth mentioning that the reference to “older adult” is extended to “dependent older adult” (DOA), since the research analysts of this study considered the principle of inseparability, since they belong to the same population group, only differing concerning the level or intensity of care demanded.

Challenges for professionals in the management of care for dependent older adults

The participants’ main challenges are related to inefficient PHC management, structural difficulties, territorial and access barriers, scarce supplies, counter-referral system bureaucracy, long waiting lines, and lack of public security. The inefficient management of PHC is evidenced by care lag and lack of priority resources and management.

PHC structural difficulties are challenging and worthy of attention by responsible bodies. Professionals aim for spaces to conduct collective activities and establish a shared care network.

The difficulties in assisting DOAs also exist in the health unit, due to territorial and access barriers:

Besides structural problems and DOA’s access to services, professionals recognize the complaints of relatives:

The particularities of some cities reveal the shortage of supplies for simple and biosafety procedures:

Other difficulties are the long waiting lines and bureaucracy in the counter-referral system for the monitoring or referral of DOAs, which hampers resolute care:

The lack of public safety in several territories expressed the reality of Brazilian cities.

Strategies and suggestions of professionals for the care of dependent older adults

Interprofessional communication, hiring professionals and specialists, reception, therapeutic and community groups, training and continuing education actions with caregivers and relatives, and home visits, were necessary strategies for DOA care. The professionals stated that elderly healthcare requires interdisciplinary and multiprofessional articulations to form a more efficient care network.

The participants realized the lack of human resources in several areas, highlighting the need to hire specialists to strengthen ESF care.

The intention to receive DOAs in the health service was evident in the search for a resolutive strategy for everyday problems.

The professionals recognized community groups as initiatives favorable to care to promote the health of DOAs. In some health services, complementary, integrative practices are valuable to this audience.

Actions based on interdisciplinary practices stem from professionals to assist DOA’s caregivers and relatives.

Professionals stressed home visits mediated by health education actions as a crucial care resource, especially for DOAs who do not attend the health center or live alone.

Discussion

As for the professional’s challenges regarding the care of DOAs in PHC, the professionals’ perception showed that the management of health services directed to this population is inefficient. Ravioli et al.²⁰20 Ravioli AF, Soarez PC, Scheffer MC. Modalidades de gestão de serviços no Sistema Único de Saúde: revisão narrativa da produção científica da Saúde Coletiva no Brasil (2005-2016). Cad Saude Publica 2018; 34(4):e00114217. analyzed the management of services in the SUS, from 2005 to 2016, and detected administrative difficulties for managers, such as “[...] low operational capacity, lack of budgetary, financial, and administrative autonomy, poor quality controls, external political influence, excessive bureaucracy to hire staff, making adjustments to the structure and to buy supplies, medicines, and equipment”.

In general, inefficient management actions challenge PHC’s underpinning processes, from recruiting human resources to organizing services and purchasing supplies. Public managers need to know their problems, study health indicators so that they know how to plan, structure, organize and evaluate technical-scientific and political-institutional actions, and establish projects that can intervene on the health status of the population²¹21 Martins CC, Waclawovsky AJ. Problemas e desafios enfrentados pelos gestores públicos no processo de gestão em saúde. Rev Gest Sist Saúde 2015; 4(1):100-109.. Managers and professionals providing health care must rethink their work²²22 Leite MT, Nardino J, Hildebrandt LM, Santos AM, Martins RV. Gestão do cuidado na estratégia saúde da família: revisão narrativa. Rev Aten Saude 2016; 14(48):106-115. based on users’ needs²³23 Silva SS, Assis MMA, Santos AM. The nurse as the protagonist of care management in the Estratégia Saúde da Família: different analysis perspectives. Texto & Contexto Enferm 2017; 26(3):e1090016..

Analyzing the elderly healthcare model, Veras and Oliveira²⁴24 Veras RP, Oliveira M. Envelhecer no Brasil: a construção de um modelo de cuidado. Cien Saude Colet 2018; 23(6):1929-1936. point out that, in current health systems, fragmented care and poor coordination issues can be solved from integrated care models. To this end, the authors suggest redesigning the care levels, which ensures a coherent flow of education, health promotion, and problem prevention actions, creating a care line favoring older adults’ reception and the monitoring of palliative care.

The lack of space to develop work with DOAs was also identified in the research on the Brazilian Primary Health Care Structure Census²⁵25 Poças KC, Freitas, LRS, Duarte EC. Censo de estrutura da Atenção Primária à Saúde no Brasil (2012): estimativas de coberturas potenciais. Epidemiol Serv Saúde [periódico na Internet]. 2017 [acessado 2020 Maio 14]; 26(2):275-284. Disponível em: https://www.scielo.br/pdf/ress/v26n2/2237-9622-ress-26-02-00275.pdf
https://www.scielo.br/pdf/ress/v26n2/223... , which may be related to the use of houses adapted for health units’ functioning, often without specific planning or project.

The territorial barriers and the lack of accessibility to health services identified in this study are reflected in care coverage, as they fragment the care cycle, break users’ attendance, and weaken bonds with professionals²⁶26 Almeida PF, Medina MG, Fausto MCR, Giovanella L, Bousquat A, Mendonça MHM. Coordenação do cuidado e Atenção Primária à Saúde no Sistema Único de Saúde. Saúde debate [periódico na Internet]. 2018 Set [acessado 2020 Junho 05]; 42(n. esp. 1):244-260. Disponível em: http://www.scielo.br/scielo.php?script=sci_arttext&pid=S0103-11042018000500244&lng=pt
http://www.scielo.br/scielo.php?script=s... . In the Census carried out by Poças et al.²⁵25 Poças KC, Freitas, LRS, Duarte EC. Censo de estrutura da Atenção Primária à Saúde no Brasil (2012): estimativas de coberturas potenciais. Epidemiol Serv Saúde [periódico na Internet]. 2017 [acessado 2020 Maio 14]; 26(2):275-284. Disponível em: https://www.scielo.br/pdf/ress/v26n2/2237-9622-ress-26-02-00275.pdf
https://www.scielo.br/pdf/ress/v26n2/223... , the situations found are similar to the inadequate structure of physical environments and difficult transportation and access, especially for older adults and the disabled.

The scarce supplies for necessary procedures were among the difficulties associated with the production of care in the ESF in different Brazilian regions. The lack of required materials for dressings in DOAs and bedridden patients becomes an unworkable task. Other studies²⁵25 Poças KC, Freitas, LRS, Duarte EC. Censo de estrutura da Atenção Primária à Saúde no Brasil (2012): estimativas de coberturas potenciais. Epidemiol Serv Saúde [periódico na Internet]. 2017 [acessado 2020 Maio 14]; 26(2):275-284. Disponível em: https://www.scielo.br/pdf/ress/v26n2/2237-9622-ress-26-02-00275.pdf
https://www.scielo.br/pdf/ress/v26n2/223... ^,2727 Lima CA, Moreira KS, Barbosa BCS, Souza Júnior RL, Pinto MQC, Costa SM. Atenção integral à comunidade: autoavaliação das equipes de saúde da família. Av Enferm [periódico na Internet]. 2019 [acessado 2020 Maio 21]; 37(3):303-312. Disponível em: http://www.scielo.org.co/pdf/aven/v37n3/0121-4500-aven-37-03-303.pdf
http://www.scielo.org.co/pdf/aven/v37n3/... showed a macro problem of poor resource management in the country.

The multiple DOA’s demands require intersectoral health care actions. However, challenges in the consolidation of comprehensive care for this public are pointed out, such as the difficulty of articulating with the care network and bureaucratization so that DOAs are accepted in all their complexity¹⁴14 Schenker M, Costa DH. Avanços e desafios da atenção à saúde da população idosa com doenças crônicas na Atenção Primária à Saúde. Cien Saude Colet [periódico na Internet]. 2019 Abr [acessado 2020 Maio 17]; 24(4):1369-1380. Disponível em: https://www.scielo.br/pdf/csc/v24n4/1413-8123-csc-24-04-1369.pdf
https://www.scielo.br/pdf/csc/v24n4/1413... . This articulation favors care comprehensiveness and must consider all the territory’s resources, from health services, squares, churches, clubs, to professional centers and associations, in order to meet affective, health, social, economic, cultural, religious, educational, and leisure’s demands for older adults²⁸28 Kantorski LP, Coimbra VCC, Oliveira NA, Nunes CK, Pavani FM, Sperb LCSO. Atenção psicossocial infantojuvenil: interfaces com a rede de saúde pelo sistema de referência e contrarreferência. Texto & Contexto Enferm 2017; 26(3):e1890014..

The bureaucracy of the referral and counter-referral system and the long and lengthy waiting lists for attending DOAs in medical specialties interrupts the continuity of care in the therapeutic itinerary. Schenker and Costa¹⁴14 Schenker M, Costa DH. Avanços e desafios da atenção à saúde da população idosa com doenças crônicas na Atenção Primária à Saúde. Cien Saude Colet [periódico na Internet]. 2019 Abr [acessado 2020 Maio 17]; 24(4):1369-1380. Disponível em: https://www.scielo.br/pdf/csc/v24n4/1413-8123-csc-24-04-1369.pdf
https://www.scielo.br/pdf/csc/v24n4/1413... characterize the referral to specialized care as fragmented and out of context, weakening the DOAs’ care.

Kantorski et al.²⁸28 Kantorski LP, Coimbra VCC, Oliveira NA, Nunes CK, Pavani FM, Sperb LCSO. Atenção psicossocial infantojuvenil: interfaces com a rede de saúde pelo sistema de referência e contrarreferência. Texto & Contexto Enferm 2017; 26(3):e1890014. show that the referral and the counter-referral system must be considered an essential resource in the line of care, since, if well structured, it promotes the efficient flow of referrals of users to the different levels of care and recommends the integration of services in a committed and effective manner.

Another factor is the lack of public security to carry out activities, especially home visits to older adults. Sturbelle et al.²⁹29 Sturbelle ICS, Pai DD, Tavares JP, Trindade LL, Riquinho DL, Ampos LF. Violência no trabalho em saúde da família: estudo de métodos mistos. Acta Paul Enferm 2019; 32(6):632-641. emphasize that violence in health services increases by the day. In PHC, services are developed in the community, whether in health units, in other spaces, and their own homes. This brings professionals closer to the territory and can expose them to violence, especially in drug trafficking areas. This situation becomes more severe in the capitals due to urbanization, associated with crime escalation.

Brazilian police struggle with containing violence as they face the growing factions (organized and well-equipped criminal groups) and their insecure working conditions. Souza and Minayo³⁰30 Souza ER, Minayo MCS. Segurança pública num país violento. Cad Saude Publica [periódico na Internet]. 2017[acessado 2020 Maio 14]; 33(3):e00036217. Disponível em: https://www.scielo.br/pdf/csp/v33n3/ 1678-4464-csp-33-03-e00036217.pdf
https://www.scielo.br/pdf/csp/v33n3/ 167... point out that the solution would not be just to provide the police with more armaments, but excellent training, daily support in conflicted areas, adequate rest, and emotional protection - not forgetting the need for investments in infrastructure in the police and health services for the safety of health workers²⁹29 Sturbelle ICS, Pai DD, Tavares JP, Trindade LL, Riquinho DL, Ampos LF. Violência no trabalho em saúde da família: estudo de métodos mistos. Acta Paul Enferm 2019; 32(6):632-641..

Concerning the strategies and suggestions of professionals for the DOA care in PHC, improving the articulation with the interdisciplinary and multiprofessional team stands out through an approach centered on comprehensive and continuous care. The repercussions transpose the biomedical model and configure the very users’ involvement with their support network, bringing shared responsibility to the therapeutic care set³¹31 Budib MB, Zulim MI, Oliveira VM, Matos VTG. Integrated continuous care: collaborating with the elderly functionality. Biosci J 2020; 36(1):266-275..

In China, researchers show that interdisciplinary care is beneficial to improve the performance of chronic DOA’s conditions, exemplifying that patients with Alzheimer’s disease have significant functional gains with this approach³²32 Chen C, Huang Y, Liu C, Xu Y, Zheng L, Li J. Effects of an interdisciplinary care team on the management of alzheimer's disease in China. J Gerontol Nursing 2019; 45(5):39-45..

The multidisciplinary team’s valorization in the scope of DOA care management has been a significant challenge for public health policies, with an urgent need for expanded care that considers strategies for structuring and reorganizing services and changes in the work process³³33 Santos SC, Tonhom SFR, Komatsu RS. Saúde do idoso: reflexões acerca da integralidade do cuidado. Rev Bras Promoç Saúde 2016; 29:118-127.. In this sense, the clinical knowledge and technologies are still preferred and can be added to the commitment and bond, performing more integrated intersectoriality and interdisciplinarity practices to expand and strengthen the daily lives of ESF teams³⁴34 Santos DS, Mishima SM, Merhy EE. Processo de trabalho na Estratégia de Saúde da Família: potencialidades da subjetividade do cuidado para reconfiguração do modelo de atenção. Cien Saude Colet [periódico na Internet]. 2018 Mar [acessado 2020 Maio 21]; 23(3):861-870. Disponível em: https://www.scielo.br/pdf/csc/v23n3/1413-8123-csc-23-03-0861.pdf
https://www.scielo.br/pdf/csc/v23n3/1413... .

In the search for this type of care, the reports issue suggestions to put the professionals in the service and hire specialists to work with DOAs. The incorporation of professionals in the health care network is highlighted as the desire of the participants of this research, since its fixation consolidates the therapeutic bonds with the registered population, increasing territorial recognition and strengthening health practice, which enhances DOAs’ resolutive health care³⁵35 Xavier GTO, Nascimento VB, Carneiro N Jr. Atenção domiciliar e sua contribuição para a construção das Redes de Atenção à Saúde sob a óptica de seus profissionais e de usuários idosos. Rev Bras Geriatr Gerontol [periódico na Internet]. 2019 [acessado 2020 May 17]; 22(2):e180151. Disponível em: https://www.scielo.br/pdf/rbgg/v22n2/pt_1809-9823-rbgg-22-02-e180151.pdf
https://www.scielo.br/pdf/rbgg/v22n2/pt_... ^,3636 Rissardo LK, Carreira L. Organization of healthcare and assistance to the elderly indigenous population: synergies and particularities of the professional context. Rev Esc Enferm USP 2014; 48(1):72-79..

It is noteworthy that it is necessary to observe factors such as the health unit’s location, worker’s age, function, level of expertise, pressure, and satisfaction in the work activity to hire a professional. Failure to observe these factors can lead to turnover, as highlighted by 42.3% of PHC doctors in a study developed in Chongqing, China³⁷37 Wen T, Zhang Y, Wang X, Tang G. Factors influencing turnover intention among primary care doctors: a cross-sectional study in Chongqing, China. Hum Resour Health 2018; 16:10., whose researchers found the need to reformulate the incentives and work proposals for fixing and the continuity of professional care in PHC³⁷37 Wen T, Zhang Y, Wang X, Tang G. Factors influencing turnover intention among primary care doctors: a cross-sectional study in Chongqing, China. Hum Resour Health 2018; 16:10..

From this perspective, the recruitment of specialists in Geriatrics and Gerontology can provide or consolidate more resolutive care to DOAs, facilitating work in healthcare networks³⁸38 Cabral R, Gomes Dellaroza MS, Carvalho BG, Zani AV. Elderly care in primary health care from the perspective of health professionals. Cienc Cuid Saúde [serial on Internet] 2019 [acessado 2020 Maio 17];18(2):e450261. Disponível em: http://periodicos.uem.br/ojs/index.php/CiencCuidSaude/article/view/45026/pdf_1
http://periodicos.uem.br/ojs/index.php/C... ^,3939 Baptistini APF, Zanon CJ. O sistema de informação na gestão do cuidado: estudo de caso em instituição de longa permanência para idosos. Estud Interdiscip Envelhec 2019; 24(1):63-74..

User reception was highlighted as a diversified resource with multiple interfaces in the health of DOAs, which can interfere during the implementation of care, and is a challenge for health teams⁴⁰40 Rocha FCV, Ferreira BR, Silva FP, Oliveira ADS, Amorim FCM. Elderly welcoming in primary health care: the user perspective. Rev Pesqui 2018; 10(3):669-674.. Regarding ‘reception’, professionals’ statements are in line with the National Humanization Policy, as reception favors a space for listening and receiving DOAs and other users⁴¹41 Brasil. Ministério da Saúde (MS). HumanizaSUS: política nacional de humanização. Brasília: MS; 2004..

In this study, the realization of community groups was highlighted as a reality in health services from several professionals’ initiative. In contrast, the absence of groups focused exclusively on DOAs was also observed. The literature highlights support groups as methods to expand care for DOAs, emphasizing prevention and health promotion, even though older adults’ participation in these groups occurs as adherence to treatment, when there is already a health problem¹⁴14 Schenker M, Costa DH. Avanços e desafios da atenção à saúde da população idosa com doenças crônicas na Atenção Primária à Saúde. Cien Saude Colet [periódico na Internet]. 2019 Abr [acessado 2020 Maio 17]; 24(4):1369-1380. Disponível em: https://www.scielo.br/pdf/csc/v24n4/1413-8123-csc-24-04-1369.pdf
https://www.scielo.br/pdf/csc/v24n4/1413... .

Elderly health requires a network-type care logic, comprehensive care, and macro or micromanagement aspects. For the implementation of this care, management must make the necessary articulations for the network’s composition and the priority care plan⁴²42 Sacco RCCS, Cardoso PRR, Escalda PMF, Assis MG, Guimarães SMF. Avaliação da microgestão em Unidades Básicas de Saúde em ações para idosos em uma região de saúde do Distrito Federal, Brasil. Cien Saude Colet [periódico na Internet]. 2019 Jun [acessado 2020 Maio 17]; 24(6):2173-2183. Disponível em: https://www.scielo.br/pdf/csc/v24n6/1413-8123-csc-24-06-2173.pdf
https://www.scielo.br/pdf/csc/v24n6/1413... .

Regarding family caregivers, the lack of support and guidance is sensitive. The professionals revealed the objective of intensifying the perspective for older adults’ families, as they are the primary care providers. Araújo et al.⁴³43 Araújo LF, Castro JLC, Santos, JVO. A família e sua relação com o idoso: um estudo de representações sociais. Psicol Pesq 2018; 12(2):14-23. postulate the concept that actions for the family’s empowerment are not sufficient and the family context must be understood to assist in relationships and care with DOAs. Public policies must promote care and feasibility so that families can provide care, observing how older adults see themselves in the family context, which interferes with the execution of practices that facilitate daily activities.

In care management, the family must be viewed in a multidimensional context, valuing the uniqueness of family interpersonal relationships, giving meaning to living, experience, religion, and culture³³33 Santos SC, Tonhom SFR, Komatsu RS. Saúde do idoso: reflexões acerca da integralidade do cuidado. Rev Bras Promoç Saúde 2016; 29:118-127..

The idea that strengthening PHC is a global strategy is highlighted. In Thailand, training programs developed over a decade indicated that, once the multiple competencies of PHC members were established, the resolution of complex problems in different local contexts was expanded, enhancing the care outcomes of teams from low- and middle-income countries⁴⁴44 Suriyawongpaisal P, Aekplakorn W, Leerapan B, Lakha F, Srithamrongsawat S, von Bormann S. Assessing system-based trainings for primary care teams and quality-of-life of patients with multimorbidity in Thailand: patient and provider surveys. BMC Fam Pract 2019; 20(1):85..

Home visit is an excellent care strategy for DOAs in the professionals’ perception. The consolidation of this strategy is highlighted as supporting a study conducted in rural Japanese communities, in which nursing students disseminate preventive actions, encompassing individual and environmental perspectives of well-being in community life⁴⁵45 Iwasaki R, Hirai K, Kageyama T, Satoh T, Fukuda H, Kai H, Makino K, Magilvy K, Murashima S. Supporting elder persons in rural Japanese communities through preventive home visits by nursing students: a qualitative descriptive analysis of students' reports. Public Health Nurs 2019; 36(4):557-563..

In effect, these findings corroborate the ‘portrait’ of Canadian PHC, highlighting the care potential in the home context, highlighting the improved experiences for patients and caregivers, which leads to lower healthcare costs, mainly when care is provided by expanded interprofessional teams⁴⁶46 Akhtar S, Loganathan M, Nowaczynski M, Sinha S, Condon A, Ewa V, Kirk JC, Pham T-N. Aging at home: a portrait of home-based primary care across Canada. Healthc Q 2019; 22(1):30-35..

Final considerations

Elderly care associated with social, physical, or emotional types of dependence resulting from older adults’ longevity requires institutions and professionals to adopt attitudes that determine effective care standards and promote a practice that can improve the quality of health and life for older adults and their relatives. This practice must be anchored in dialogue, interrelation of those involved, and in the incorporation of innovative actions that enable favorable conditions for the engagement of caregivers.

The management of DOA care is a unique, broad, and complex circumstance, where the health operator assumes challenging dimensions to make decisions involving protection, prevention, and health promotion, prioritizing resources and service management. The structural and administrative conditions of PHC services in the cities studied showed weaknesses in DOA care at home and the health unit, underscoring the inefficient management, hardships in the physical, territorial, and access areas, lack of care material, administrative bureaucracy in the counter-referral system, long waiting lists, and lack of public security.

The professionals revealed that the difficulties in health services are related to several factors, but they struggle to supply them, undertaking actions emphasizing greater integration of the multidisciplinary team, adaptations to improve the work environment, and the involvement of community resources. They stressed that community groups, complementary integrative practices, and health education are fundamental for the development of protective actions for DOAs and their relatives.

In the universe of elderly care in PHC, especially for care-dependent older adults, the challenges faced by professionals are diverse and complex, requiring an effective inter-professional and intersectoral articulation to expand resolutive care. Thus, there is a need for reworking health practices geared to older adults, considering structural, administrative, social and political aspects, which promote changes in essential conditions to manage daily demand, in the health units and the homes.

References

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