ABSTRACT

OBJECTIVES:

To analyze if primary and specialized care physicians know and use care coordination mechanisms between healthcare levels.

METHODS:

Cross-sectional survey study, with the application of the COORDENA-BR instrument to primary and specialized care physicians in a public heathcare network, medium-sized municipality, from June to October 2019. The questionnaire addresses knowledge, frequency of sending and receiving, purpose, characteristics and difficulties in using feedback or mutual adaptation and standardization mechanisms to promote coordination of care service between healthcare levels.

RESULTS:

Feedback instruments such as referral and reply letters, hospital discharge report and WhatsApp are widely known by professionals of both levels, without significant differences. Clinical sessions and protocols are not well-known, especially in specialized care, which supposes a low usage of standardization mechanisms to a better coordination between the healthcare levels. Despite being well-known and easy, traditional feedback instruments such as referral and reply letters are not widely used. Fewer physicians knew the protocols, mainly in specialized care. They pointed difficulties in their application, such as insufficient exams and unavailable supplies in the healthcare network. Clinical sessions were unknown and registered low participation frequency. Care overload, low institutionalization and time constraints were barriers identified for the incorporation of care coordination mechanisms in the work process in primary and specialized care, in addition to those related to the provision of health services in the network.

CONCLUSION:

We conclude the fragmentation of the system and care can be faced in the complementarity of measures that make it possible to know the mechanisms, develop professional skills, institutionalize and promote organizational conditions for the effective use of coordination mechanisms throughout the healthcare network.

DESCRIPTORS:
Intersectoral Collaboration; Comprehensive Health Care; Health Care Levels; Health Services Administration

INTRODUCTION

The diversity and complexity of health needs in the face of nutritional, epidemiological and demographic transition combined with technological advances incorporated into heath care have, somehow, expanded the available therapeutic arsenal and configured a pattern of multiple contacts with health professionals and services, especially in cases of multimorbidity¹1. Ovretveit J. Does clinical coordination improve quality and save money? London (UK): Health Foundation; 2011 [cited 2020 Feb 2]. Available from: https://www.health.org.uk/publications/does-clinical-coordination-improve-quality-and-save-money
https://www.health.org.uk/publications/d... ^,22. Vázquez ML, Vargas I, Unger JP, De Paepe P, Mogollón-Pérez AS, Samico I, et al. Evaluating the effectiveness of care integration strategies in different healthcare systems in Latin America: the EQUITY-LA II quasi-experimental study protocol. BMJ Open. 2015;5(7):e007037. https://doi.org/10.1136/bmjopen-2014-007037
https://doi.org/10.1136/bmjopen-2014-007... , expanding the need for strategies for the care coordination. The use of instruments for communication and care articulation between these healthcare levels strengthens the coherence, efficiency and quality of care³3. Akbari A, Mayhew A, Al-Alawi MA, Grimshaw J, Winkens R, Glidewell E, et al. Interventions to improve outpatient referrals from primary care to secondary care. Cochrane Database Syst Rev. 2008;(4):CD005471. https://doi.org/10.1002/14651858.CD005471.pub2
https://doi.org/10.1002/14651858.CD00547... . Despite the consensus around their need, a set of evidences indicates incipience in the knowledge and use of coordination mechanisms by professionals in different contexts of health systems⁴4. Oliveira CRF, Samico IC, Mendes MFM, Vargas I, Vázquez ML. Conhecimento e uso de mecanismos para articulação clínica entre níveis em duas redes de atenção à saúde de Pernambuco, Brasil. Cad Saude Publica. 2019;35(4):e00119318. https://doi.org/10.1590/0102-311X00119318
https://doi.org/10.1590/0102-311X0011931... ^,55. Aller MB, Vargas I, Coderch J, Vázquez ML. Doctors' opinion on the contribution of coordination mechanisms to improving clinical coordination between primary and outpatient secondary care in the Catalan national health system. BMC Health Serv Res. 2017;17(1):842. https://doi.org/10.1186/s12913-017-2690-5
https://doi.org/10.1186/s12913-017-2690-... .

The duplication of diagnostic and therapeutic procedures, unnecessary referrals and the non-conciliation of treatments are both results and one of the facets that show the incoherence between the healthcare levels and their low quality⁶6. European Union. Tools and methodologies to assess integrated care in Europe. Report by the Expert Group on Health Systems Performance Assessment. Luxembourg: Publications Office of the European Union; 2017 [cited 2020 Feb 10]. Available from: http://publications.euopa.eu/others/agents/index_en.htm
http://publications.euopa.eu/others/agen... . The lack of interaction and trust between professionals in primary health care (PHC) and specialized care (SC) are part of the problem⁷7. Jesus RPFS, Espírito Santo ACG, Mendes MFM, Samico IC. Percepção dos profissionais sobre a coordenação entre níveis de atenção à saúde em dois municípios pernambucanos de grande porte. Interface (Botucatu);2018;22(65):423-34. https://doi.org/10.1590/1807-57622017.0026
https://doi.org/10.1590/1807-57622017.00... ^,88. Vázquez M-L, Vargas I, Garcia-Subirats I, Unger JP, De Paepe P, Mogollón-Pérez AS, et al. Doctors' experience of coordination across care levels and associated factors. A cross-sectional study in public healthcare networks of six Latin American countries. Soc Sci Med. 2017;182:10-9. https://doi.org/10.1016/j.socscimed.2017.04.001
https://doi.org/10.1016/j.socscimed.2017... , whose coping cannot depend only on the intention and initiative of health professionals, being dependent on labor, organizational, relational conditions and the characteristics of the system as a whole⁹9. Vargas I, Mogollón-Pérez AS, De Paepe P, Silva MRF, Unger JP, Vázquez ML. Barriers to healthcare coordination in market-based and decentralized public health systems: a qualitative study in healthcare networks of Colombia and Brazil. Health Policy Plan. 2016;31(6):736-48. https://doi.org/10.1093/heapol/czv126
https://doi.org/10.1093/heapol/czv126... .

Coordination instruments aim to minimize the barriers between the healthcare levels, favoring continuity by transfer of information, exchange of knowledge and improvement of care¹⁰10. Hartz ZM, Contandriopoulos AP. Integralidade da atenção e integração de serviços de saúde: desafios para avaliar a implantação de um “sistema sem muros.” Cad Saude Publica. 2004;20 Supl 2:S331-6. https://doi.org/10.1590/s0102-311x2004000800026
https://doi.org/10.1590/s0102-311x200400... ^,1111. Mendes EV. Desafios do SUS. Brasília, DF: CONASS; 2019 [cited 2020 Mar 6]. Available from: http://www.conass.org.br/biblioteca/desafios-do-sus/
http://www.conass.org.br/biblioteca/desa... . Coordination mechanisms can be classified as standardization mechanisms and mutual feedback or adaptation mechanisms¹¹11. Mendes EV. Desafios do SUS. Brasília, DF: CONASS; 2019 [cited 2020 Mar 6]. Available from: http://www.conass.org.br/biblioteca/desafios-do-sus/
http://www.conass.org.br/biblioteca/desa... ^,1212. Terraza Núñez R, Vargas Lorenzo I, Vázquez Navarrete ML. La coordinación entre niveles asistenciales: una sistematización de sus instrumentos y medidas. Gac Sanit. 2006;20(6):485-95. https://doi.org/10.1157/13096516
https://doi.org/10.1157/13096516... . Standardization mechanisms aim to harmonize or systematize the work process, professionals' skills and work results, such as clinical sessions and shared protocols. Mutual adaptation or feedback mechanisms are based on communication and the formal and informal information exchange between professionals for shared care planning, such as referral forms and reply letters, discharge report and phone line¹²12. Terraza Núñez R, Vargas Lorenzo I, Vázquez Navarrete ML. La coordinación entre niveles asistenciales: una sistematización de sus instrumentos y medidas. Gac Sanit. 2006;20(6):485-95. https://doi.org/10.1157/13096516
https://doi.org/10.1157/13096516... . These instruments are important for promoting adjustments in clinical situations that involve a large set of information, highly specialized and, at the same time, interdependent activities¹³13. Gittell JH. Organizing work to support relational co-ordination. Int J Hum Resour Manag. 2000;11(3):517-39. https://doi.org/10.1080/095851900339747
https://doi.org/10.1080/095851900339747... .

The proper use of coordination mechanisms would be one of the facilitators of communication and integration between PHC and SC⁴4. Oliveira CRF, Samico IC, Mendes MFM, Vargas I, Vázquez ML. Conhecimento e uso de mecanismos para articulação clínica entre níveis em duas redes de atenção à saúde de Pernambuco, Brasil. Cad Saude Publica. 2019;35(4):e00119318. https://doi.org/10.1590/0102-311X00119318
https://doi.org/10.1590/0102-311X0011931... ^,1414. Almeida PF, Santos AM. Primary Health Care: care coordinator in regionalized networks? Rev Saude Publica. 2016;50:80. https://doi.org/10.1590/S1518-8787.2016050006602
https://doi.org/10.1590/S1518-8787.20160... . National studies on the topic often focus on PHC teams and physicians¹⁴14. Almeida PF, Santos AM. Primary Health Care: care coordinator in regionalized networks? Rev Saude Publica. 2016;50:80. https://doi.org/10.1590/S1518-8787.2016050006602
https://doi.org/10.1590/S1518-8787.20160... ^,1515. Chaves LA, Jorge AO, Cherchiglia ML, Reis IA, Santos MAC, Santos AF, et al. Integração da atenção básica à rede assistencial: análise de componentes da avaliação externa do PMAQ-AB. Cad Saude Publica. 2018;34(2):e00201515. https://doi.org/10.1590/0102-311X00201515
https://doi.org/10.1590/0102-311X0020151... , since the guidelines of national policies define that the care coordination in health care networks (HCN) is responsibility of this healthcare level. Based on the experience and perception of the two main actors involved in the activities of articulation of care between the different services of the HCN, this article aims at analyzing if physicians from PHC and SC know and use mechanisms to care coordination between healthcare levels.

METHODS

This is a cross-sectional survey study conducted in PHC and SC services in the Unified Health System (SUS) network of a medium-sized municipality (338,480 inhabitants in 2019) in the state of Bahia, Brazil. A census of PHC and SC medical professionals working in these services was conducted between June and October 2019. The PHC had coverage of 60%, 47% by the Family Health Strategy (FHS) and 13% by traditional health centers (HC)¹⁶16. Ministério da Saúde (BR), Secretaria de Atenção Primária à Saúde. Informação e gestão da atenção básica (e-Gestor AB)]. Brasília, DF; 2019 [cited 2019 May 18]. Available from: https://egestorab.saude.gov.br
https://egestorab.saude.gov.br... .

The sample included all PHC doctors (FHS and traditional HC) and medical specialists that received regular primary care referrals for specialized consultations. Participants worked for at least three months in the respective service at the beginning of the field research, according to information from the municipal administration. We interviewed 120 of the 136 physicians. Individuals interviewed and losses are described according to their service in Table 1.

To conduct our study, the validated and translated instrument into Portuguese COORDENA-BR^aaSamico I, Albuquerque PC, Vázquez ML, Vargas I, Unger JP, De Paepe P, et al. Questionário de articulação/coordenação entre os níveis de atenção: COORDENAR-BR. Recife, PE: Instituto de Medicina Integral Prof. Fernando Figueira (IMIP); 2015 [cited 2018 Jul 9]. Available from: http://www.equity-la.eu/upload/seccions/files/COORDENA_BR%282%29.pdf, which is based on the theoretical model developed by Vázquez et al.²2. Vázquez ML, Vargas I, Unger JP, De Paepe P, Mogollón-Pérez AS, Samico I, et al. Evaluating the effectiveness of care integration strategies in different healthcare systems in Latin America: the EQUITY-LA II quasi-experimental study protocol. BMJ Open. 2015;5(7):e007037. https://doi.org/10.1136/bmjopen-2014-007037
https://doi.org/10.1136/bmjopen-2014-007... and Vargas et al.⁹9. Vargas I, Mogollón-Pérez AS, De Paepe P, Silva MRF, Unger JP, Vázquez ML. Barriers to healthcare coordination in market-based and decentralized public health systems: a qualitative study in healthcare networks of Colombia and Brazil. Health Policy Plan. 2016;31(6):736-48. https://doi.org/10.1093/heapol/czv126
https://doi.org/10.1093/heapol/czv126... , was used to analyze the coordination of care between healthcare levels. The complete questionnaire addresses: experience in coordinating information and in clinic management between healthcare levels and general perception about coordination between levels in the network; professionals' interaction factors; coordination mechanism knowledge and use; suggestions for improvement; organizational, work factors and attitudes related to coordination between levels; sociodemographic data of the interviewees. The items related to the knowledge and use of coordination mechanisms between levels are the focus of our article.

The questionnaire addresses knowledge, frequency of sending and receiving, purpose, characteristics and difficulties in using feedback (or mutual adaptation) and standardization mechanisms to promote coordination of care between healthcare levels, which comprised the analyzed variables. The questionnaire underwent minor adjustments to the local scenario (for example, the type of protocol adopted in the HCN) and some updates, such as the addition of a question about knowledge on the electronic medical record and Telehealth implemented in the municipality, according to management information, and WhatsApp, technology increasingly used in interprofessional communication¹⁷17. Giordano V, Koch H, Godoy-Santos A, Belangero WD, Pires RES, Labronici P. WhatsApp messenger as an adjunctive tool for telemedicine: an overview. Interact J Med Res. 2017;6(2):e11. https://doi.org/10.2196/ijmr.6214
https://doi.org/10.2196/ijmr.6214... . Use purposes and difficulties were identified by open questions. Likewise, there were open fields to explain the reasons for not regularly receiving the referral and reply letters and the discharge report.

For closed questions, the Likert scale and dichotomous answers (yes / no) were used, in addition to multiple choice questions. Some variables of interest were categorized for a better comparison between PHC and SC physicians. The answers “always” and “often” as well as “daily” and “weekly” were considered as high frequency; “Sometimes” and “very few times” as well as “monthly” and “less frequently” as low frequency; and “never” represented the non-use of the instrument (zero frequency). The questionnaire was digitized using the KoBo Toolbox 1.4.8 software, available on Samsung Galaxy Tab A tablets.

Data was collected by face-to-face interviews conducted by trained researchers, with an average duration of 26.6 minutes, being recorded on an audio device for transcription and categorization of open questions. To guarantee the quality of collection and reliability of data, field activities were directly monitored and questionnaire completion in the database were evaluated.

A descriptive analysis of the variables was performed by healthcare level, using absolute (n) and relative (%) frequencies. Data were processed using the Stata program, version 15.0 (Stata Corporation, College Station, USA). Statistical differences between the proportions were evaluated by Pearson's chi-squared test. Qualitative data from open responses were categorized.

This study was approved by the Research Ethics Committee of the Universidade Federal da Bahia, under opinion no. 3.334.464 and CAAE: 09503419.1.0000.5556 with permission of the municipality.

RESULTS

Sample Characteristics

The largest proportion of professionals was of men (57%), with women mostly in PHC (55%), younger, aged 25 to 34 years (40%). SC physicians were professionals for a longer time and most of them (55%) attended public universities. In PHC, most of the professionals attended private colleges and about 60% had no medical residency training. Most of the specialists had employment contracts with a lower week workload (80%) and also worked in the private sector (93%), unlike PHC professionals (Table 2).

Knowledge and Use of Care Coordination Mechanisms between Healthcare Levels

The formal mechanism of coordination between levels best known among PHC physicians was the referral form and reply letters (86%), followed by the discharge report (78%). Specialists knew more about the discharge report (91%), followed by the referral and reply letters (70%). Regarding standardization instruments, the protocols shared between levels, developed by the Brazilian Ministry of Health and the municipality, were better known by PHC physicians when compared with specialists (p = 0.004). Table 3 shows that the PHC and SC joint clinical sessions were little known by physicians of both levels, and practically unknown by specialists (p = 0.001).

About 36% of PHC physicians were unaware of the existence of an institutional phone line and 45% were unaware of Telehealth. Among SC physicians, the phone line was widely known, and Telehealth was unknown. The electronic medical record seemed to be present in part of the PHC services, but absent in the SC, since it was unknown by most of the professionals. WhatsApp was the most popular instrument by professionals at both levels. We observed a significant difference between the knowledge of PHC and SC physicians about most of the coordination mechanisms of care service (Table 3).

After recognizing the existence, we sought to understand the frequency of use of the coordination mechanisms, categorized as “high,” “low” or “never.” Most professionals knew the referral and reply letters instruments. However, only 44% of PHC physicians mentioned high sending frequency of the referral form to the specialist, who, in turn, mentioned low receiving frequency. On the other hand, fewer specialists knew such instruments, and few frequently sent reply letters to PHC physicians, about half of whom reported never receiving them. Discharge report receiving by physicians at the first level was more frequent. The fact that these instruments are sent via patient was mentioned by the interviewees as a reason for not receiving them. Among the PHC physicians that knew the shared protocols (42), the most had a high frequency of using this tool (93%). Few specialists knew it (22); of these, 64% used it with high frequency. The clinical sessions were little known by professionals of both levels and even less used by specialists. WhatsApp was widely known by professionals (more frequent in SC services), but with little or no use (Table 3).

Purpose and Characteristics of the Use of Coordination Mechanisms between Healthcare Levels

Among the professionals that knew the mechanisms and mentioned using them with some frequency, their purpose was evaluated by open questions, whose content was categorized. They mostly considered that the referral, reply letters and discharge forms were used to exchange information between healthcare levels. For PHC and SC physicians, the main function of the protocols was to guide the care and standardize the service, with quality of care and reduction of costs being mentioned. In the opinion of the few physicians that knew the clinical sessions, the main objectives would be to improve knowledge and standardize conducts (Table 4).

The use of the phone line and WhatsApp was justified by the ease and speed, although most did not use them (Table 3). Many PHC physicians reported that this communication tool could speed up access to the specialist in situations of greatest urgency, in addition to ensuring that the information reached the other level (Table 4), which did not happen in the case of the referral and reply letters conducted by the user. Qualitative data showed that physicians used phone and WhatsApp to contact only professionals they already knew. PHC physicians that worked in units in rural areas stressed that access to the internet was made possible by the professional himself.

Regarding the characteristics of the use of the coordination mechanisms, in the referral form filled in by the PHC physicians, the specialists received more information about the reasons for referral (100%), personal data and clinical history. In the reply letters by specialists, physicians at the first level received more information about treatments and diagnosis (Table 4). Exam results were the least frequent information. Among the PHC physicians that received the reply letters (28), half considered that they answered the reason for the referral and only one third arrived in a timely manner. Nevertheless, more than half of the specialists did not know or did not use such instruments.

According to most PHC physicians, hospital discharge reports were also not received in a timely manner for decision-making. All professionals considered that this instrument contained information on pharmacological treatment, diagnosis and procedures performed. However, the indications for monitoring users were the least frequent information (Table 4). In open questions, professionals reported that this instrument was instituted by residency programs in two public hospital units in the network and that its use was already well established in most private hospitals, as shown in Table 4.

All PHC physicians, with some frequency, participated in training on protocols. Most of them considered that the institution provided time to participate in clinical sessions, whose content was considered appropriate. The number of specialists that knew such instruments was lower, with the participation of specialists in clinical sessions being almost zero.

Difficulties in Using Coordination Mechanisms between Healthcare Levels

For physicians from PHC and SC, the mechanism that presented the greatest difficulties of use was the shared protocols, due to the barriers to perform the tests and the unavailability of standardized supplies. More than half of the specialists reported difficulties to participate in clinical sessions, with lack of time being pointed out as the main difficult (Table 5).

Table 5 shows that most participants found no barriers in using the referral and reply letters and the discharge report. In open questions, most respondents pointed out the fact that these documents are sent via patient as a reason for not receiving them. Lack of time to fill in the forms due to physicians' workload was mentioned by PHC and SC physicians as a difficulty. The interviewees' statements also referred to the low functionality (objectivity) of the printed material and the lack of standardization, management request and the physicians' low interest.

DISCUSSION

Only mechanisms known to professionals in their daily practice could be used to obtain better coordination. Feedback instruments such as referral and reply letters, hospital discharge report and WhatsApp are widely known by professionals of both levels. Clinical sessions and protocols were little known, especially in SC.

Knowing is a necessary condition; however, it is not enough to include such mechanisms in the work process. The traditional referral forms and reply letters, although available to most of family health teams in the country¹⁸18. Fausto MCR, Giovanella L, Mendonça MHM, Seidl H, Gagno J. A posição da Estratégia Saúde da Família na rede de atenção à saúde na perspectiva das equipes e usuários participantes do PMAQ-AB 2012. Saude Debate. 2014;38 N° Espec:13-33. https://doi.org/10.5935/0103-1104.2014S003
https://doi.org/10.5935/0103-1104.2014S0... , had low or no frequency of use, especially in SC, although difficulties in using them have not been identified.

Our study confirms that reply letters was not used as a feedback mechanism, evidence frequently reiterated by a set of studies⁴4. Oliveira CRF, Samico IC, Mendes MFM, Vargas I, Vázquez ML. Conhecimento e uso de mecanismos para articulação clínica entre níveis em duas redes de atenção à saúde de Pernambuco, Brasil. Cad Saude Publica. 2019;35(4):e00119318. https://doi.org/10.1590/0102-311X00119318
https://doi.org/10.1590/0102-311X0011931... ^,1414. Almeida PF, Santos AM. Primary Health Care: care coordinator in regionalized networks? Rev Saude Publica. 2016;50:80. https://doi.org/10.1590/S1518-8787.2016050006602
https://doi.org/10.1590/S1518-8787.20160... , considering also the experience of specialists, an actor little incorporated in the studies on coordination. Oliveira et al.⁴4. Oliveira CRF, Samico IC, Mendes MFM, Vargas I, Vázquez ML. Conhecimento e uso de mecanismos para articulação clínica entre níveis em duas redes de atenção à saúde de Pernambuco, Brasil. Cad Saude Publica. 2019;35(4):e00119318. https://doi.org/10.1590/0102-311X00119318
https://doi.org/10.1590/0102-311X0011931... draw attention to the bureaucratic character in understanding this mechanism, despite being the most common and, often, the only one found in the HCN. Nevertheless, few doctors considered it for longitudinal monitoring. In the case of PHC, the delay in the arrival of the reply letters may delay actions of active search in cases that require more immediate interventions. The lower frequency of information about exams in the instrument also reduces the chances of reducing unnecessary duplication¹²12. Terraza Núñez R, Vargas Lorenzo I, Vázquez Navarrete ML. La coordinación entre niveles asistenciales: una sistematización de sus instrumentos y medidas. Gac Sanit. 2006;20(6):485-95. https://doi.org/10.1157/13096516
https://doi.org/10.1157/13096516... , an aspect to be considered by management in training processes.

Insofar as the regulatory centers did not mediate the flow of clinical information, but rather the users themselves, non-institutionalization prevailed, which, in turn, could interfere with the professionals' decision to use it. This result is compatible with those found in other studies, which also identified a prevalent pattern of referral and reply letters sending via users in networks with different characteristics⁴4. Oliveira CRF, Samico IC, Mendes MFM, Vargas I, Vázquez ML. Conhecimento e uso de mecanismos para articulação clínica entre níveis em duas redes de atenção à saúde de Pernambuco, Brasil. Cad Saude Publica. 2019;35(4):e00119318. https://doi.org/10.1590/0102-311X00119318
https://doi.org/10.1590/0102-311X0011931... .

Another feedback tool, the hospital discharge report, despite dealing with the relationship with hospital services, was well known, and an important percentage of PHC physicians received it. In the municipality, the experience of implantation via medical residency in public hospitals has made the discharge report present in the PHC work process, reinforcing the premise that coordination mechanisms must be part of every point of the care service¹²12. Terraza Núñez R, Vargas Lorenzo I, Vázquez Navarrete ML. La coordinación entre niveles asistenciales: una sistematización de sus instrumentos y medidas. Gac Sanit. 2006;20(6):485-95. https://doi.org/10.1157/13096516
https://doi.org/10.1157/13096516... . Likewise, such experience, triggered by a training program, seems to have been decisive in making receiving it more frequent than reply letters, even though driving via the user remained, the lack of information and indications for monitoring in PHC and low sharing of test results, a finding also found in another study⁴4. Oliveira CRF, Samico IC, Mendes MFM, Vargas I, Vázquez ML. Conhecimento e uso de mecanismos para articulação clínica entre níveis em duas redes de atenção à saúde de Pernambuco, Brasil. Cad Saude Publica. 2019;35(4):e00119318. https://doi.org/10.1590/0102-311X00119318
https://doi.org/10.1590/0102-311X0011931... . The set of results seems to indicate that, in addition to the institutionalization of coordination mechanisms, their use by professionals includes the recognition of networking and PHC as a regular search and longitudinal care service¹⁴14. Almeida PF, Santos AM. Primary Health Care: care coordinator in regionalized networks? Rev Saude Publica. 2016;50:80. https://doi.org/10.1590/S1518-8787.2016050006602
https://doi.org/10.1590/S1518-8787.20160... , which can be facilitated by training processes in the undergraduate course and in professional action⁹9. Vargas I, Mogollón-Pérez AS, De Paepe P, Silva MRF, Unger JP, Vázquez ML. Barriers to healthcare coordination in market-based and decentralized public health systems: a qualitative study in healthcare networks of Colombia and Brazil. Health Policy Plan. 2016;31(6):736-48. https://doi.org/10.1093/heapol/czv126
https://doi.org/10.1093/heapol/czv126... .

Although Telehealth is a strategy in the scope of information and communication technologies to promote greater access, improve quality and professional training implemented in the country since 2007 to connect PHC to other levels¹⁹19. Santos AF, D'Agostino M, Bouskela MS, Fernandéz A, Messina LA, Alves HJ. Uma visão panorâmica das ações de telessaúde na América Latina. Rev Panam Salud Publica. 2014;35(5-6):465-70., it was unknown by SC physicians. Electronic referral means (or e-referrals) can decrease the time to access the specialist, reduce costs and improve coordination, with a greater degree of success if implemented in networks with salaried specialists²⁰20. Bodenheimer T. Coordinating care: a perilous journey through the Health Care System. N Engl J Med. 2008;358(10):1064-71. https://doi.org/10.1056/NEJMhpr0706165
https://doi.org/10.1056/NEJMhpr0706165... , such as the municipality of study. Among the devices offered by Telessaúde Brasil Redes, telediagnosis, in which exams are sent to specialists for issuing reports, could be a better explored strategy.

WhatsApp, a mutual adjustment mechanism for informal communication¹¹11. Mendes EV. Desafios do SUS. Brasília, DF: CONASS; 2019 [cited 2020 Mar 6]. Available from: http://www.conass.org.br/biblioteca/desafios-do-sus/
http://www.conass.org.br/biblioteca/desa... , was widely known, but used to contact only known professionals, which also signals that close relationships are necessary for collaboration⁸8. Vázquez M-L, Vargas I, Garcia-Subirats I, Unger JP, De Paepe P, Mogollón-Pérez AS, et al. Doctors' experience of coordination across care levels and associated factors. A cross-sectional study in public healthcare networks of six Latin American countries. Soc Sci Med. 2017;182:10-9. https://doi.org/10.1016/j.socscimed.2017.04.001
https://doi.org/10.1016/j.socscimed.2017... ^,2121. Schot E, Tummers L, Noordegraaf M. Working on working together. A systematic review on how healthcare professionals contribute to interprofessional collaboration. J Interprof Care. 2019;22(1):11. https://doi.org/10.1080/13561820.2019.1636007
https://doi.org/10.1080/13561820.2019.16... . Countryside areas also presented internet access problems.

In PHC, investments in computerization with the implementation of electronic medical records have been observed in recent years¹⁸18. Fausto MCR, Giovanella L, Mendonça MHM, Seidl H, Gagno J. A posição da Estratégia Saúde da Família na rede de atenção à saúde na perspectiva das equipes e usuários participantes do PMAQ-AB 2012. Saude Debate. 2014;38 N° Espec:13-33. https://doi.org/10.5935/0103-1104.2014S003
https://doi.org/10.5935/0103-1104.2014S0... . In the municipality, since 2018, the HealthRise Project, in partnership with public universities, has expanded the implementation of the citizen's electronic medical record in the FHS, which may explain the greater knowledge of the mechanism at this level. However, there was no progress in relation to shared medical records, vertical information system¹²12. Terraza Núñez R, Vargas Lorenzo I, Vázquez Navarrete ML. La coordinación entre niveles asistenciales: una sistematización de sus instrumentos y medidas. Gac Sanit. 2006;20(6):485-95. https://doi.org/10.1157/13096516
https://doi.org/10.1157/13096516... , present in only 14% of primary care teams in the country, especially in municipalities with more than 100,000 inhabitants²²22. Lima JG, Giovanella L, Fausto MCR, Bousquat A, Silva EV. Atributos essenciais da Atenção Primária à Saúde: resultados nacionais do PMAQ-AB. Saude Debate. 2018;42 N° Espec 1:52-66. https://doi.org/10.1590/0103-11042018S104
https://doi.org/10.1590/0103-11042018S10... . Because they are not shared, in the context of small and independent providers, professionals are unable to access clinical records in the various services of the HCN²⁰20. Bodenheimer T. Coordinating care: a perilous journey through the Health Care System. N Engl J Med. 2008;358(10):1064-71. https://doi.org/10.1056/NEJMhpr0706165
https://doi.org/10.1056/NEJMhpr0706165... .

Among the coordination mechanisms by standardization¹²12. Terraza Núñez R, Vargas Lorenzo I, Vázquez Navarrete ML. La coordinación entre niveles asistenciales: una sistematización de sus instrumentos y medidas. Gac Sanit. 2006;20(6):485-95. https://doi.org/10.1157/13096516
https://doi.org/10.1157/13096516... , shared protocols and clinical sessions were even more residual, mainly in SC. A study conducted in two HCN in the state of Pernambuco also showed low knowledge about the protocols prepared by the Brazilian Ministry of Health by SC physicians⁴4. Oliveira CRF, Samico IC, Mendes MFM, Vargas I, Vázquez ML. Conhecimento e uso de mecanismos para articulação clínica entre níveis em duas redes de atenção à saúde de Pernambuco, Brasil. Cad Saude Publica. 2019;35(4):e00119318. https://doi.org/10.1590/0102-311X00119318
https://doi.org/10.1590/0102-311X0011931... , which seems to question their “sharing” nature. Although less well known than the feedback instruments, there was high use, more expressive in PHC, that is, those that knew used the protocols to standardize the care, as found by Oliveira et al.⁴4. Oliveira CRF, Samico IC, Mendes MFM, Vargas I, Vázquez ML. Conhecimento e uso de mecanismos para articulação clínica entre níveis em duas redes de atenção à saúde de Pernambuco, Brasil. Cad Saude Publica. 2019;35(4):e00119318. https://doi.org/10.1590/0102-311X00119318
https://doi.org/10.1590/0102-311X0011931... At the same time, professionals pointed out difficulties in incorporating the protocol guidelines, since the HCN did not offer the necessary supplies and services. Clinical sessions, on the other hand, were not part of the SC work process, a result also found in another study⁴4. Oliveira CRF, Samico IC, Mendes MFM, Vargas I, Vázquez ML. Conhecimento e uso de mecanismos para articulação clínica entre níveis em duas redes de atenção à saúde de Pernambuco, Brasil. Cad Saude Publica. 2019;35(4):e00119318. https://doi.org/10.1590/0102-311X00119318
https://doi.org/10.1590/0102-311X0011931... , and were partially present in the PHC, requiring a guarantee of time, by the management, to enable adherence to this coordination mechanism⁹9. Vargas I, Mogollón-Pérez AS, De Paepe P, Silva MRF, Unger JP, Vázquez ML. Barriers to healthcare coordination in market-based and decentralized public health systems: a qualitative study in healthcare networks of Colombia and Brazil. Health Policy Plan. 2016;31(6):736-48. https://doi.org/10.1093/heapol/czv126
https://doi.org/10.1093/heapol/czv126... .

Our study did not analyze possible associations between knowledge and the use of coordination mechanisms by physicians, nor did it cover other actors and sources of information that might need its implementation and use in the HCN, such as monitoring references, frequency of holding clinical sessions and making available protocols, among others. Our study used an instrument applied in national and international scenarios, which proved to be adequate for the identification and in-depth analysis of coordination mechanisms, characterizing and qualifying aspects of use that can be appropriated by researchers and health managers involved in the improvement coordination of care service.

CONCLUSIONS

PHC attributions has been increasing, with the successive incorporation of care services previously provided at other levels²⁰20. Bodenheimer T. Coordinating care: a perilous journey through the Health Care System. N Engl J Med. 2008;358(10):1064-71. https://doi.org/10.1056/NEJMhpr0706165
https://doi.org/10.1056/NEJMhpr0706165... and, in the Brazil, decentralization of actions and programs²³23. Facchini LA, Tomasi E, Dilélio AS. Qualidade da Atenção Primária à Saúde no Brasil: avanços, desafios e perspectivas. Saude Debate. 2018;42 N° Espec 1:208-23. https://doi.org/10.1590/0103-11042018S114
https://doi.org/10.1590/0103-11042018S11... , in addition to increased care overload, mainly attributed to insufficient human resources⁹9. Vargas I, Mogollón-Pérez AS, De Paepe P, Silva MRF, Unger JP, Vázquez ML. Barriers to healthcare coordination in market-based and decentralized public health systems: a qualitative study in healthcare networks of Colombia and Brazil. Health Policy Plan. 2016;31(6):736-48. https://doi.org/10.1093/heapol/czv126
https://doi.org/10.1093/heapol/czv126... and an excess of users per team¹⁴14. Almeida PF, Santos AM. Primary Health Care: care coordinator in regionalized networks? Rev Saude Publica. 2016;50:80. https://doi.org/10.1590/S1518-8787.2016050006602
https://doi.org/10.1590/S1518-8787.20160... . Problems related to the insufficient supply of services in the HCN¹⁴14. Almeida PF, Santos AM. Primary Health Care: care coordinator in regionalized networks? Rev Saude Publica. 2016;50:80. https://doi.org/10.1590/S1518-8787.2016050006602
https://doi.org/10.1590/S1518-8787.20160... also discourage and hinder the use of standardization mechanisms. In this scenario, there seems to be a consensus that coordination activities will not arise spontaneously²⁰20. Bodenheimer T. Coordinating care: a perilous journey through the Health Care System. N Engl J Med. 2008;358(10):1064-71. https://doi.org/10.1056/NEJMhpr0706165
https://doi.org/10.1056/NEJMhpr0706165... without a guarantee of adequate working conditions such as sufficient time, payment for performance of coordination activities²⁰20. Bodenheimer T. Coordinating care: a perilous journey through the Health Care System. N Engl J Med. 2008;358(10):1064-71. https://doi.org/10.1056/NEJMhpr0706165
https://doi.org/10.1056/NEJMhpr0706165... and stable employment bonds that allow professionals to develop them, as well as training processes aimed at networking and recognizing PHC role⁸8. Vázquez M-L, Vargas I, Garcia-Subirats I, Unger JP, De Paepe P, Mogollón-Pérez AS, et al. Doctors' experience of coordination across care levels and associated factors. A cross-sectional study in public healthcare networks of six Latin American countries. Soc Sci Med. 2017;182:10-9. https://doi.org/10.1016/j.socscimed.2017.04.001
https://doi.org/10.1016/j.socscimed.2017... ^,99. Vargas I, Mogollón-Pérez AS, De Paepe P, Silva MRF, Unger JP, Vázquez ML. Barriers to healthcare coordination in market-based and decentralized public health systems: a qualitative study in healthcare networks of Colombia and Brazil. Health Policy Plan. 2016;31(6):736-48. https://doi.org/10.1093/heapol/czv126
https://doi.org/10.1093/heapol/czv126... .

Network formation and connection between workers is imperative in health care, since there is no self-sufficiency²⁴24. Franco TB. Redes de cuidado: conexão e fluxos para o bom encontro com a saúde. In: Almeida PF, Santos AM, Souza MKB, editores. Atenção Primária à Saúde na coordenação do cuidado em Regiões de Saúde. Salvador, BA: EDUFBA; 2015. p.261-76.. The involvement of all SUS workers, including in the investigative processes, seems to be the most promising and possible way, since mutual adjustment mechanisms facilitate the approximation and direct communication among professionals as well as contributing to increase interprofessional trust¹²12. Terraza Núñez R, Vargas Lorenzo I, Vázquez Navarrete ML. La coordinación entre niveles asistenciales: una sistematización de sus instrumentos y medidas. Gac Sanit. 2006;20(6):485-95. https://doi.org/10.1157/13096516
https://doi.org/10.1157/13096516... . In some cases, such mechanisms are characterized as lightweight technologies, which could be encouraged without the need for large resources.

Finally, coordination mechanisms have great potential to improve interprofessional collaboration²2. Vázquez ML, Vargas I, Unger JP, De Paepe P, Mogollón-Pérez AS, Samico I, et al. Evaluating the effectiveness of care integration strategies in different healthcare systems in Latin America: the EQUITY-LA II quasi-experimental study protocol. BMJ Open. 2015;5(7):e007037. https://doi.org/10.1136/bmjopen-2014-007037
https://doi.org/10.1136/bmjopen-2014-007... . Furthermore, as important as implementing those that do not yet exist (such as shared electronic medical records) is to create adequate conditions for the use of such mechanisms, many of which are already present in the HCN, as showed in our study. It is in the complementarity of measures that make it possible to know, develop professional skills, institutionalize and promote organizational conditions for the effective use of coordination mechanisms in all HCN that the fragmentation of the system and care service can be faced.

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