Abstract

Introduction

One of the significant milestones of the Brazilian Psychiatric Reform (BPR) movement was the approval of Law No. 10.216/2001. This law aimed to reorient the care model for people with mental disorders and their families, as well as to build care practices through the creation and strengthening of services that replace mental institutions, based on care in freedom and a territorial basis. The Brazilian experience of implementing a Mental Health (MH) care model in line with the paradigms of the BPR shows a new social place for mental disorders, guided by the Psychosocial Care (PC) model. This model, which makes the center of care the person in their different spheres in a socio-community context¹1 Amarante P, Nunes MO. A reforma psiquiátrica no SUS e a luta por uma sociedade sem manicômios. Cienc Saude Colet. 2018; 23(6):2067-74. doi: 10.1590/1413-81232018236.07082018.
https://doi.org/10.1590/1413-81232018236... ^,22 Micheli GA. Not just a one-man revolution: the multifaceted anti-asylum watershed in Italy. Hist Psychiatry. 2019; 30(2):133-49.^, is particularly relevant in the context of our study’s location, the Federal District of Brazil.

The Psychosocial Care Network (RAPS) establishes the points of care in the Brazilian National Health System (SUS) – Brazil’s universal and public health system – for comprehensive and humanized care for people with mental disorders and substance use disorders. RAPS has regional management and an open, community-based model of care, guaranteeing freedom and social coexistence through services, the community, and the territory. It is structured around the following points of care: Primary Health Care (PHC) – Primary Care Units (UBS) and the Expanded Family Health Center (NASF) – Strategic PC – different types of Psychosocial Care Centers (CAPS), which can be for the care of mental disorders or substance use disorders (alcohol and other drugs – AD) in adults or children – Urgent and emergency care, Home Care, Reception Units and Hospital Care³3 Brasil. Ministério da Saúde. Portaria nº 3.088, de 26 de dezembro de 2011. Institui a Rede de Atenção Psicossocial para pessoas com sofrimento ou transtorno mental e com necessidades decorrentes do uso de crack, álcool e outras drogas, no âmbito do Sistema Único de Saúde. Diário Oficial da União. 27 Dez 2011.^,44 Sampaio ML, Bispo JP Jr. Rede de Atenção Psicossocial: avaliação da estrutura e do processo de articulação do cuidado em saúde mental. Cad Saude Publica. 2021; 37(3):e00042620. doi: 10.1590/0102-311X00042620.
https://doi.org/10.1590/0102-311X0004262... .

For Avelar & Malfitano⁵5 Avelar MR, Malfitano APS. Entre o suporte e o controle: a articulação intersetorial de redes de serviços. Cienc Saude Colet. 2018; 23(10):3201-10. doi: 10.1590/1413-812320182310.13872018.
https://doi.org/10.1590/1413-81232018231... , network care can be understood as:

This understanding is in line with the proposal of the PC model, integrating SUS services, promoting comprehensive care for people with mental and substance use disorders and their families, encouraging professionals to work together, and articulating the most diverse points of care⁴4 Sampaio ML, Bispo JP Jr. Rede de Atenção Psicossocial: avaliação da estrutura e do processo de articulação do cuidado em saúde mental. Cad Saude Publica. 2021; 37(3):e00042620. doi: 10.1590/0102-311X00042620.
https://doi.org/10.1590/0102-311X0004262... ^,55 Avelar MR, Malfitano APS. Entre o suporte e o controle: a articulação intersetorial de redes de serviços. Cienc Saude Colet. 2018; 23(10):3201-10. doi: 10.1590/1413-812320182310.13872018.
https://doi.org/10.1590/1413-81232018231... .

Therefore, networking retains a relational character between its actors and is an extremely important light technology. Merhy et al.6 present light technology as a strategy for relational processes between health professionals, users, and their families, individually or collectively, with care based on listening, welcoming, dialog, bonding, and meeting one another, in the act, a living work.

Studies in Brazil have discussed the importance and challenges faced in implementing network care coordination practices between the various points of care in the RAPS. Fonseca and Gallassi⁷7 Fonseca RMAM, Gallassi AD. Práticas de cuidado extramuros nos Centros de Atenção Psicossocial Álcool e outras Drogas: a ocupação cidadã. Interface (Botucatu). 2021; 25:e200369. doi: 10.1590/interface.200369.
https://doi.org/10.1590/interface.200369... discuss the extramural practices developed by professionals working in the CAPS-AD of the Federal District (DF), pointing out that there are still few care actions outside the physical structure of the services, and even though there are extramural activities, they occur on an occasional and temporary basis. Gama et al.⁸8 Gama CAP, Lourenço RF, Coelho VAA, Campos CG, Guimarães DA. Os profissionais da Atenção Primária à Saúde diante das demandas de saúde mental: perspectivas e desafios. Interface (Botucatu). 2021; 25:e200438. doi: 10.1590/interface.200438.
https://doi.org/10.1590/interface.200438... discuss how mental health demands are dealt with in primary health care in the state of Minas Gerais (MG) and identify problems in the organization and articulation of the RAPS, which hindered care practices in line with the paradigms of the BPR. Sampaio and Bispo Júnior⁴4 Sampaio ML, Bispo JP Jr. Rede de Atenção Psicossocial: avaliação da estrutura e do processo de articulação do cuidado em saúde mental. Cad Saude Publica. 2021; 37(3):e00042620. doi: 10.1590/0102-311X00042620.
https://doi.org/10.1590/0102-311X0004262... evaluated the structure and practices of mental health care coordination in Bahia. They identified a fragmented network, with centralization in specialist services, lack of established flows, insufficient structure and communication difficulties with primary care and other points of care.

In this sense, this study set out to explore and characterize the network articulation practices developed by professionals working in two specific points of the RAPS - the CAPS-AD and the UBS - highlighting which strategies are used, as well as the difficulties and challenges that cross their implementation following the PC model.

Method

This is a qualitative, exploratory and descriptive study carried out between May 2022 and January 2023. It included health professionals working in CAPS-AD and UBS in the seven health regions of the DF. The CAPS-AD is an open-door service with a multidisciplinary team, specifically for comprehensive and continuous care for people with substance use disorders, seeking to provide social reintegration and strengthen family and territorial ties⁹9 Freire MAB, Yasui S. O território, as redes e suas (im)potências: o cuidado aos usuários de álcool e outras drogas em um CAPSad. Fractal Rev Psicol. 2022; 34:e5992. doi: 10.22409/1984-0292/2022/v34/5992.
https://doi.org/10.22409/1984-0292/2022/... . The UBS is people’s gateway to the SUS, whose function is to promote comprehensive health care for the population in its territory. It has Family Health Strategy (ESF) teams, made up of a doctor, nurse, nursing technician and community health agents, oral health teams, made up of a dentist and an oral health technician, and NASF, made up of specialists who provide matrix support/technical pedagogical support to the primary care teams and direct assistance to users¹⁰10 Brasil. Ministério da Saúde. Secretaria de Atenção à Saúde. Departamento de Atenção Básica. Saúde Mental [Internet]. Brasília: Ministério da Saúde; 2013 [citado 25 Fev 2023]. Disponível em: http://189.28.128.100/dab/docs/portaldab/publicacoes/caderno_34.pdf.
http://189.28.128.100/dab/docs/portaldab... ^,1111 Ribeiro SP, Cavalcanti MLT. Atenção Primária e Coordenação do Cuidado: dispositivo para ampliação do acesso e a melhoria da qualidade. Cienc Saude Colet. 2020; 25(5):1799-808. doi: 10.1590/1413-81232020255.34122019.
https://doi.org/10.1590/1413-81232020255... .

The DF is located in the Midwest region of Brazil. It has a population of 3,094,325 inhabitants spread over 33 administrative regions (ARs)¹²12 Brasília. Governo do Distrito Federal. Secretaria de Estado de Saúde. Plano Distrital de Saúde 2020-2023 [Internet]. Brasília: Secretaria de Estado de Saúde; 2019 [citado 25 Fev 2023]. Disponível em: https://www.conass.org.br/wp-content/uploads/2022/02/2020_06_01_PDS-2020-2023_Aprovada_CSDF_v_publicizada.pdf
https://www.conass.org.br/wp-content/upl... – equivalent to “neighborhoods” – with Brasília being the third most populous city in the country (IBGE/2021)¹³13 Instituto Brasileiro de Geografia e Estatística. Estimativas da população residente para os municípios e para as unidades da federação [Internet]. Rio de Janeiro: IBGE; 2021 [citado 25 Fev 2023]. Disponível em: https://www.ibge.gov.br/Estatisticas/Sociais/Populacao/9103-Estimativas-De-Populacao.Html?=&T=Resultados
https://www.ibge.gov.br/Estatisticas/Soc... . These ARs are grouped into seven health regions, according to geographical and epidemiological layout, and have health services of different complexities (primary care, medium and high complexity)¹⁴14 Brasília. Governo do Distrito Federal. Plano Diretor de Saúde Mental do Distrito Federal 2020-2023 [Internet]. Brasília: Governo do Distrito Federal; 2019 [citado 25 Fev 2023]. Disponível em: https://www.saude.df.gov.br/documents/37101/183291/PDSM_2020_2023.pdf/153f5dd8-c54b-3711-680c-28a0cb23dd01?t=1648938776840
https://www.saude.df.gov.br/documents/37... . The matrix support activities are articulated between the health regions and their superintendencies so that they jointly have administrative and shared attributions with the other social actors in the network. Still, there is no common schedule or methodology. Each health region in the DF draws up its matrix support actions according to the demand and specificities of its catchment area¹⁴14 Brasília. Governo do Distrito Federal. Plano Diretor de Saúde Mental do Distrito Federal 2020-2023 [Internet]. Brasília: Governo do Distrito Federal; 2019 [citado 25 Fev 2023]. Disponível em: https://www.saude.df.gov.br/documents/37101/183291/PDSM_2020_2023.pdf/153f5dd8-c54b-3711-680c-28a0cb23dd01?t=1648938776840
https://www.saude.df.gov.br/documents/37... .

The inclusion criteria for the study were: (i) working in a CAPS-AD or UBS in the DF, (ii) being over ¹⁸18 Kinoshita RT, Trino AT, Guimarães CS, Castro CA, Prado CMAS. Atenção psicossocial e bem viver: relato de experiência de um Projeto Terapêutico Singular pelas dimensões da Felicidade Interna Bruta. Saude Debate. 2020; 44(3 Spec No):320-32., and (iii) agreeing to take part in the study. At least two professionals from each health region were included, one of whom worked in a UBS and the other in a CAPS-AD, sharing the same health region to explore the dynamics of network articulation in each of the seven regions.

The strategy used to collect the data was intra-method triangulation¹⁵15 Santos KS, Ribeiro MC, Queiroga DEU, Silva IAP, Ferreira SMS. O uso de triangulação múltipla como estratégia de validação em um estudo qualitativo. Cienc Saude Colet. 2020; 25(2):655-64. doi: 10.1590/1413-81232020252.12302018.
https://doi.org/10.1590/1413-81232020252... , using two techniques: a semi-structured synchronous interview and a structured asynchronous interview, conducted virtually and focusing on the relationship between the UBS and CAPS-AD. For the semi-structured interview, the following trigger themes were used: the strategies used to weave the network, the existing difficulties for dialog between the two points of care in the RAPS, and actions to expand the network. The structured interview dealt with sociodemographic aspects, perceptions of networking and the practices used to create networks, and what strategies are being used to continue this work. The aim of choosing these different interview methods was to offer different opportunities for the interviewees to reflect and contribute, either by speaking or by writing, and thus capture the perceptions of these professionals more fully. This is because some may feel uncomfortable explaining difficulties and problems at work when interviewed live and do so in written form. In addition, intra-method triangulation in the data analysis process provided greater support for structuring categories based on themes that recurred and were consolidated throughout the speeches.

The data was analyzed using the content analysis technique guided by Bardin¹⁶16 Santos FM. Análise de conteúdo: a visão de Laurence Bardin. Rev Eletronica Educ. 2012; 6(1):383-7., covering three stages: (1) pre-analysis of the material collected, carried out by carefully reading and re-reading the transcripts of both interviews to systematize and get closer to the findings to be analyzed; (2) the elaboration of the thematic axes which took place through the repetition and relevance of the material; given the objectives of the study, a cut was made in registration units and the practices of i) matrix support; ii) meetings with the network; and iii) referral, discussed concomitantly, were classified into a single thematic axis. Finally, (3) treatment, inference and interpretation of the material collected.

The research was approved by the Research Ethics Committee of the University of Brasília (CAAE: 53345921.7.0000.8093), and the Foundation for Teaching and Research in Health Sciences of the Federal District (CAAE: 53345921.7.3001.5553). All participants signed the Informed Consent Form virtually.

Results and discussion

Thirty-six professionals were interviewed, 18 working in UBS and 18 working in CAPS AD, representing the seven health regions of the Federal District, with a predominance of females (33). The age range varied between 29 and 53 years, with the majority (20) in their 30s and 40s. The participants’ predominant length of time worked at CAPS AD was between 6 months and 17 years, and at UBS, it was between 5 months and 17 years. The CAPS AD interviewed 6 occupational therapists, 4 psychologists, 4 nursing technicians, 3 nurses and 1 social worker. From the UBS, 7 occupational therapists, 3 nurses, 2 nutritionists, 2 social workers, 2 physicians, 1 psychologist, and 1 physiotherapist participated. No community health agents participated in the interviews, as the matrix support activities they carry out are only between the NASF and the ESF team, not between other points of care, such as the CAPS (Frame 1).

The interviewees’ accounts were named according to i) the form of participation, semi-structured interview (ES) and structured interview (EE); ii) the order of participation, from (01) to (36); iii) professionals working in the UBS/Primary Health Care (PHC) and CAPS-AD (AD); and iv) health regions: Central Region (RC), Central-South Region (RCS), North Region (RN), South Region (RSL), East Region (RL), West Region (RO) and Southwest Region (RS).

The data collected was grouped into two broad thematic categories: the first portrays seven obstacles that challenge the implementation of networking practices to strengthen PC in the DF, and the second points to three strategies that can change this reality, presented below.

The challenges of weaving the network: common perceptions of CAPS AD and UBS workers from the seven Health Regions of the Federal District

The functioning of an articulated network between the different points of care in the RAPS depends on investment inflows, resources, and work processes that can break down the barriers that hinder and limit this practice. Although each health region has its own particularities, there were difficulties and challenges in common. In this sense, seven obstacles were identified that challenge the implementation of network articulation practices to strengthen PC and BPR:

1) Lack of matrix meetings

The participants pointed to matrix support meetings as an extremely important strategy for strengthening primary care. However, three main points make matrix support difficult: the lack of a prior schedule, the lack of planning for how these meetings will be held, and the lack of understanding among managers and professionals about this practice:

The difficulties mentioned in this study have also been identified in others in Brazil¹⁷17 Lima DKRR, Guimarães J. Articulação da Rede de Atenção Psicossocial e continuidade do cuidado em território: problematizando possíveis relações. Physis. 2019; 29(3):e290310. doi: 10.1590/S0103-73312019290310.
https://doi.org/10.1590/S0103-7331201929...

18 Kinoshita RT, Trino AT, Guimarães CS, Castro CA, Prado CMAS. Atenção psicossocial e bem viver: relato de experiência de um Projeto Terapêutico Singular pelas dimensões da Felicidade Interna Bruta. Saude Debate. 2020; 44(3 Spec No):320-32.

19 Pinheiro GEW, Kantorski LP. Apoio matricial em saúde mental na atenção primária à saúde: um estudo avaliativo e participativo. Rev Cont Saude. 2020; 20(40):199-208.

20 Iglesias A, Belotti M, Avellar LZ. Matriciamento em saúde mental: concepções, mudanças e dificuldades de profissionais da atenção básica. Psicodebate [Internet]. 2024 [citado 26 Mar 2024];10(1):191-208. Disponível em: http://psicodebate.dpgpsifpm.com.br/index.php/periodico/article/view/1090.
http://psicodebate.dpgpsifpm.com.br/inde... ^-2121 Fagundes GS, Campos MR, Fortes SLCL. Matriciamento em saúde mental: análise do cuidado às pessoas em sofrimento psíquico na Atenção Básica. Cienc Saude Colet. 2022; 26(6):2311-22. doi: 10.1590/1413-81232021266.20032019.
https://doi.org/10.1590/1413-81232021266... . Matrix support is a joint action between primary care and CAPS AD and is seen as an important strategy for promoting health and strengthening PHC and BPR. However, the lack of understanding or knowledge about matrix support and its objectives leads to an unwillingness on the part of professionals and the management itself to dedicate themselves to and encourage this practice. So, there is little effort to organize an agenda, plan actions in advance, and engage professionals. Encouraging actions that inform and stimulate teams to adopt matrix support practices can be an effective strategy for articulating the network and solving more cases.

2) Lack of a flow for referral and counter-referral cases

Participants say that users are referred via WhatsApp, email, SEI (Electronic Information System) and a physical referral form delivered by hand. The lack of criteria and guidelines to carry out this flow has an impact on case follow-up:

National studies²²22 Ribeiro SP, Cavalcanti MLT. Atenção primária e coordenação do cuidado: dispositivo para ampliação do acesso e a melhoria da qualidade. Cienc Saude Colet. 2020; 25(5):1799-808.^,2323 Mendes LS, Almeida PF. Médicos da atenção primária e especializada conhecem e utilizam mecanismos de coordenação? Rev Saude Publica. 2020; 54:1-14. discuss the weaknesses of continuity of care between PHC and the other points of care in the RAPS, pointing to the need to improve effective communication between the different levels of care with the potential to disseminate case information. In this way, the referral and counter-referral system within the RAPS is strengthened to corroborate shared care actions involving users, their families and health professionals, following the assumptions of the PC model.

3) Lack of a unified medical records system for all RAPS points of care to monitor cases

Participants say that in addition to the referral and counter-referral not having a pre-established flow, once users have been referred, they cannot monitor whether or not the person is being attended to via a unified electronic medical record system. This information is usually gathered by communicating with the user themselves or by contacting a professional from the other service who is part of their personal support network:

National studies²⁴24 Schönholzer TE, Pinto IC, Zacharias FCM, Gaete RAC, Serrano-Gallardo MDP. Implementation of the e-SUS Primary Care system: Impact on the routine of Primary Health Care professionals. Rev Lat Am Enferm. 2021; 29:e3447. doi: 10.1590/1518-8345.4174.3447.
https://doi.org/10.1590/1518-8345.4174.3... ^,2525 Santos LPR, Pereira AG, Graever L, Guimarães RM. e-SUS AB na cidade do Rio de Janeiro: projeto e implantação do sistema de informação em saúde. Cad Saude Colet. 2021; 29(Spec No):199-204. doi: 10.1590/1414-462X202199010232.
https://doi.org/10.1590/1414-462X2021990... discuss the implementation of the electronic medical record of the SUS (e-SUS) in primary care, pointing out that incorporating e-SUS can optimize work processes. However, they point out that some aspects need to be improved to break down inconsistencies in the quality of information in the system. e-SUS was seen as an interventional strategy to overcome barriers and weave the network:

4) Lack of telephone and telephone system in services

The practice of networking is once again impacted by communication barriers between services due to the lack of a telephone and an institutional telephone system, according to the study participants:

Sheridan and collaborators²⁶26 Rains LS, Johnson S, Barnett P, Steare T, Needle JJ, Carr S, et al. Early impacts of the Covid-19 pandemic on mental health care and on people with mental health conditions: framework synthesis of international experiences and responses. Soc Psychiatry Psychiatr Epidemiol. 2020; 56(1)78. doi: 10.1007/s00127-020-01924-7.
https://doi.org/10.1007/s00127-020-01924... discuss the implementation of telehealth tools in MH services worldwide and point to the increased use of applications for individual and group consultations and team meetings. These tools have enabled continuity of care, keeping alive activities that could have been extinguished in the context of the Covid-19 pandemic.

5) Lack of driver and car to travel between RAPS points of care

Participants from services located in more extensive health regions and serving rural areas were the ones who most pointed out the problem of the lack of a car and driver, especially to hold matrix meetings with more distant units:

According to Santos²⁷27 Santos EO, Pinho LB, Silva AB, Eslabão AD. Analysis of access to the psychosocial care network for users of alcohol and other drugs in rural areas. Rev Gaucha Enferm. 2022; 43:e20210229. doi: 10.1590/1983-1447.2022.20210229.en.
https://doi.org/10.1590/1983-1447.2022.2... , residents of rural areas suffer from barriers to accessing mental health care due to existing weaknesses in RAPS services, such as weak human resources for health promotion and prevention work, structural resources for transportation and communication, and financial shortages and technologies that bring teams closer to rural areas, highlighting the need for these aspects to be prioritized to facilitate and expand access to health care for residents of rural areas. An international study²⁸28 Csák R, Szécsi J, Kassai S, Márványkövi F, Rácz J. New psychoactive substance use as a survival strategy in rural marginalized communities in Hungary. Int J Drug Policy. 2020; 85:102639. doi: 10.1016/j.drugpo.2019.102639.
https://doi.org/10.1016/j.drugpo.2019.10... pointed to a high prevalence of alcohol and other drug use in rural populations and poor access to MH services for the care of this problem, highlighting not only the socioeconomic inequality between rural dwellers compared to those living in the city but also the difficulty in accessing health services.

6) Lack of time and schedule to carry out networking activities

Many of the participants mentioned that the main focus of the services is to meet the demand there, and going outside to take part in network meetings or matrix meetings, for example, is not seen as a priority and ends up taking a back seat:

According to Martinhago and Oliveira²⁹29 Martinhago F, Oliveira WF. A prática profissional nos Centros de Atenção Psicossocial II (caps II), na perspectiva dos profissionais de saúde mental de Santa Catarina. Saude Debate. 2012; 36(95):583-94., the lack of intersectoral actions hampers and restricts mental health care, stiffening network and intersectoral articulation practices, with uniprofessional and unisectoral care prevailing. The importance of knowing about existing activities in the network and in the territory allows users to participate socially in different devices, such as schools, churches, community and cultural groups, which are extramural practices that are favorable to what is recommended by the PC model.

7) Lack of human resources to carry out networking actions

The participants see the network articulation actions as an important strategy for strengthening PC and BPR. However, in addition to the lack of a timetable, planning and understanding of the actions (obstacle 1), many PHC and CAPS teams are precarious due to the lack of human resources - aggravated by the Covid-19 pandemic - which has triggered a work overload directly influencing the availability of participation in matrix support activities.

National studies have discussed the setbacks in mental health, and drug policies in Brazil since 2016, with significant disinvestment in CAPS and greater investment in private long-term and religiously-oriented services, such as therapeutic communities³⁰30 Cruz NFO, Gonçalves RW, Delgado PGG. Retrocesso da reforma psiquiátrica: o desmonte da política nacional de saúde mental brasileira de 2016 a 2019. Trab Educ Saude [Internet]. 2022 [citado 27 Mar 2024]; 18(3):e00285117. Disponível em: https://www.tes.epsjv.fiocruz.br/index.php/tes/article/view/772
https://www.tes.epsjv.fiocruz.br/index.p... ^,3131 Onocko-Campos RT. Saúde mental no Brasil: avanços, retrocessos e desafios. Cad Saude Publica. 2019; 35(11):e00156119. doi: 10.1590/0102-311X00156119.
https://doi.org/10.1590/0102-311X0015611... . This scenario of the precariousness of public health services and their workers has been aggravated by the Covid-19 pandemic, both because of the increase in demand and because of the coverage of colleagues who have been absent due to the disease, with a significant impact on their mental health. Teixeira et al.³²32 Teixeira CFS, Soares CM, Souza EA, Lisboa ES, Pinto ICM, Andrade LR, et al. A saúde dos profissionais de saúde no enfrentamento da pandemia de Covid-19. Cienc Saude Colet. 2020; 25(9):3465-74. doi: 10.1590/1413-81232020259.19562020.
https://doi.org/10.1590/1413-81232020259... conducted a study in Brazil during the pandemic and found problems affecting health workers, including the deterioration of services and the precariousness of the PHC workforce. Miranda et al.³³33 Miranda KG, Silva ICR, Fonseca RMAM, Gallassi AD. Effects of working in vulnerable contexts on the mental health of primary healthcare professionals during the Covid-19 pandemic: a mixed-methods study. BMJ Open. 2023; 13(11):e073472. doi: 10.1136/bmjopen-2023-073472.
https://doi.org/10.1136/bmjopen-2023-073... identified almost identical impacts on mental health and the use of alcohol and other drugs among PHC workers in the Federal District during the Covid-19 pandemic, regardless of socioeconomic status (more or less vulnerable) and the number of cases and deaths in the regions where they worked. In addition, they emphasized that the lack of support and leadership from the federal government and the distance from family and friends during the pandemic contributed to these professionals’ negative manifestations of MH issues.

Strategies for weaving the network: common perceptions of CAPS AD and UBS workers from the seven Health Regions of the Federal District

Although there is a lack of infrastructure, human resources and supplies for network articulation practices to be carried out satisfactorily in the view of the participants, these professionals also suggest interventional and health promotion strategies to seek improvements, such as:

1) Creation of an online portfolio with a complete network menu to be shared among all points of care

A Brazilian experience that meets this strategy was creating a website entitled “Portfolio of Inspiring Practices in Psychosocial Care” bringing together reports and illustrative media of innovative experiences in PHC between 2015 and 2020. The actions featured psychosocial approaches to welcoming, caring and empowering life, including thematic video lessons on different fields of knowledge given by specialists, encouraging the dissemination of actions that seek to strengthen the PC model³⁴34 Soalheiro N, Rabello ET, Caetano K, Lima RT, Caron E, Leal AL, et al. Ensino e pesquisa em saúde mental na atenção básica: portfólio de práticas inspiradoras em atenção psicossocial. Trab Educ Saude. 2023; 21:e00960205. doi: 10.1590/1981-7746-ojs960.
https://doi.org/10.1590/1981-7746-ojs960... .

2) Creation of continuing and permanent education programs, as well as partnerships with medical and multi-professional residency programs

The MH residency programs in Brazil are a great asset for strengthening care. The direct insertion of recently graduated professionals with different health backgrounds into care enables them to learn and exchange knowledge with professionals working in the services. This is a strong instrument for network articulation between the points of care where they are inserted and providing guidance and matrix support for the PHC teams³⁵35 Almeida ALM, Cunha MB. Unidade de acolhimento adulto: um olhar sobre o serviço residencial transitório para usuários de álcool e outras drogas. Saude Debate. 2021; 45(128):105-17. doi: 10.1590/0103-1104202112808.
https://doi.org/10.1590/0103-11042021128... .

In the studies by Nóbrega et al.³⁶36 Nóbrega MPSS, Mantovani GS, Domingos AM. Recursos, objetivos e diretrizes em uma estrutura de Rede de Atenção Psicossocial. Rev Bras Enferm. 2020; 73(1):e20170864. doi: 10.1590/0034-7167-2017-0864.
https://doi.org/10.1590/0034-7167-2017-0... , Silva et al.³⁷37 Silva AP, Morais HMM, Albuquerque MSV, Guimarães MBL, Lyra TM. Os desafios da organização em rede na atenção psicossocial especializada: o caso do Recife. Saude Debate. 2021; 45(128):66-80. doi: 10.1590/0103-1104202112805.
https://doi.org/10.1590/0103-11042021128... and Santos et al.³⁸38 Santos EO, Pinho LB, Silva AB, Eslabão AD. Analysis of access to the psychosocial care network for users of alcohol and other drugs in rural areas. Rev Gaucha Enferm. 2022; 43:e20210229. doi: 10.1590/1983-1447.2022.20210229.en.
https://doi.org/10.1590/1983-1447.2022.2... , the lack of human resources, investments in adequate equipment and continuing education actions were considered major obstacles to effective networking. This reinforces that investing in continuing and permanent education strategies, integrating the electronic medical records system, having the service’s own telephone system, and investing in transportation are essential strategies for expanding and consolidating the dialog between the RAPS points of care.

3) Raise awareness among managers and PHC professionals about the importance of matrix support, demystifying the idea that it is a work overload or a secondary priority

The literature points to extramural practices as necessary and fundamental for strengthening primary care⁷7 Fonseca RMAM, Gallassi AD. Práticas de cuidado extramuros nos Centros de Atenção Psicossocial Álcool e outras Drogas: a ocupação cidadã. Interface (Botucatu). 2021; 25:e200369. doi: 10.1590/interface.200369.
https://doi.org/10.1590/interface.200369... . Care actions outside the physical structure of the services – including matrix support – are scarce and are still being implemented and consolidated. Although such activities occur, they are not systematic and continuous, demonstrating the need for managers to incorporate them as a strategic guideline for MH care.

The interventional and health promotion strategies pointed out by the participants could alleviate many of the difficulties presented. Even though each health region has its own particularities, the challenges are quite common among them, and adopting such strategies would benefit everyone. Networking practices are congruent with live work, and it is necessary to provide spaces for dialog and active participation between all the parties involved, workers from different specialties, users, families and managers. Adopting such practices could directly impact case resolution, reduce work overload and mitigate the lack of resources for care under the PC model.

Conclusion

The study’s methodological design was qualitative, with an exploratory and descriptive approach. It did not set out to exhaust the proposed theme but to contribute to thinking about the challenges faced by CAPS AD and UBS teams in network articulations, focusing on strengthening and resolving MH practices following the paradigms of BPR, PHC and PC.

From this perspective, it is understood that the existing obstacles discussed in this study need to be addressed so that the BPR paradigm and the PC model can move forward, develop and be strengthened through the active participation of CAPS and UBS professionals in the construction of MH care actions. In addition, the interventional and health promotion strategies identified by the participants may be implemented in the Federal District’s health network to strengthen care in the context of PC.

Further studies involving service users, family members, and managers are suggested to broaden the understanding of the challenges in building network articulation practices between primary care services and MH, alcohol, and other drug services.

Acknowledgments

Both authors thank the participating health professionals who gave up their time to contribute to this very relevant discussion.

References

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