ABSTRACT

OBJECTIVE

To build and validate a logical model for health care in Specialized Rehabilitation Centers (CER) by analyzing the work process and organizational issues of centers in Rio Grande do Norte.

METHODS

This is a methodological study developed in three stages: 1) documentary research of legislation and ordinances concerning the healthcare service and the Disability Care Network (RCPD); 2) focus groups with a Census study of the CER in Rio Grande do Norte to understand and assess the daily activities of the service; and 3) systematization of the information collected and, finally, proposition and validation of the evaluative logical model.

RESULTS

The model encompassed five central categories of the work and organizational process: “demands”, “resources” (inputs, financial and workforce), “processes”, “products and results” and “mission, values and external factors”.

CONCLUSION

The logical model built was suitable for graphical representation of the work process and organizational issues of the SRC. The study showed that the functioning of the services is in line with the regulations. However, there are still organizational gaps that need to be addressed to improve the resolution capacity of the service and the articulation with other points of the network.

Rehabilitation centers, organization & administration; People with disabilities, rehabilitation; Resource Management of the Health Care Team; Evaluation of Processes and Results in Health Care; Human Resources Administration

INTRODUCTION

Due to the greater number of people living with disabilities, increased incidence of chronic diseases and population aging, the subject of rehabilitation has gained prominence in Brazil and the world¹1. Heinemann Aw, Feuerstein M, Frontera WR, Gard AS, Kaminsky LA, Negrini S, et al. Rehabilitation is a global health priority. Arch Phys Med Rehabil. 2020;101(4):728-9. https://doi.org/10.1016/j.apmr.2019.08.468
https://doi.org/10.1016/j.apmr.2019.08.4... . The agenda “Rehabilitation 2030: a call for action”, proposed by the World Health Organization (WHO), advocates universal access to rehabilitation and calls on nations to reflect on how they set up public policies, structure their assistance services and information systems¹1. Heinemann Aw, Feuerstein M, Frontera WR, Gard AS, Kaminsky LA, Negrini S, et al. Rehabilitation is a global health priority. Arch Phys Med Rehabil. 2020;101(4):728-9. https://doi.org/10.1016/j.apmr.2019.08.468
https://doi.org/10.1016/j.apmr.2019.08.4... ,²2. Rauch A, Negrini S, Cieza A. Toward strengthening rehabilitation in health systems: methods used to develop a Who package of rehabilitation interventions. Arch Phys Med Rehabil. 2019;100(11):2205-11. https://doi.org/10.1016/j.apmr.2019.06.002
https://doi.org/10.1016/j.apmr.2019.06.0... . In Brazil, the scarce literature and instruction regarding rehabilitation services, offered by Specialized Rehabilitation Centers (CER), indicates the urgency and relevance of studies that evaluate this area of care.

According to the WHO, one in seven people in the world lives with disabilities³3. World Health Organization. Disability. Geneva: WHO; 2020 [cited 2020 Jan 26]. Available from: http://www.who.int/disabilities/en/
http://www.who.int/disabilities/en/... . Brazilian data are out of date, since the most current overview is provided by the 2010 Census. According to this survey, 23.9% of the Brazilian population has at least one type of disability, and prevalence increases with age⁴4. Brazilian Institute of geography and Statistics. Demographic Census 2010: general characteristics of the population, religion and disability. Rio de Janeiro: IBGE; 2012..

Created by Ordinance No. 793/2012, which established the Disability Care Network (RCPD), the CER are health services providing specialized rehabilitation care for people with disabilities throughout the national territory⁵5. Ministry of Health (BR). Ordinance No. 793 of 24 April 2012. It establishes the Care Network for people with disabilities within the Unified Health System. Brasília, DF; 2012 [cited 2020 Jul 29]. Available from: https://bvsms.saude.gov.br/bvs/saudelegis/gm/2012/prt0793_24_04_2012.html
https://bvsms.saude.gov.br/bvs/saudelegi... . These are reference centers for RCPD and for Brazilian public policies for disability care⁶6. Pereira JS, Machado WCA. Implementation of specialized rehabilitation center: advantages and disadvantages pointed out by municipal health managers. Rev Ter Ocup Univ São Paulo. 2015;26(3):373-81. https://doi.org/10.11606/issn.2238-6149.v26i3p373-381
https://doi.org/10.11606/issn.2238-6149.... .

Specialized Rehabilitation Centers can assist people with physical, hearing, visual, intellectual and multiple disabilities. According to the epidemiological profile of the territory, these centers can be authorized in three formats: CER II, comprising two types of rehabilitation; CER III, comprising three types of rehabilitation; and CER IV, comprising four types of rehabilitation (physical, visual, hearing and intellectual), in addition to the orthopedics workshop⁵5. Ministry of Health (BR). Ordinance No. 793 of 24 April 2012. It establishes the Care Network for people with disabilities within the Unified Health System. Brasília, DF; 2012 [cited 2020 Jul 29]. Available from: https://bvsms.saude.gov.br/bvs/saudelegis/gm/2012/prt0793_24_04_2012.html
https://bvsms.saude.gov.br/bvs/saudelegi... .

Among the aspects of health evaluation, the analysis of implementation of programs or services through logical models has been gaining prominence⁷7. Mills T, Lawton R, Sheard L. Advancing complexity science in healthcare research: the logic of logic models. BMC Med Res Methodol. 2019;19(1):55. https://doi.org/10.1186/s12874-019-0701-4
https://doi.org/10.1186/s12874-019-0701-... . The logical model is a graphical representation that shows the various possible relationships between the planned activities and the expected results⁸8. Rohwer AA, Booth a, Pfadenhauer L, Brereton L, Gerhardus a, Mozygemba K, et al. Guidance on the use of logic models in health technology assessments of complex interventions. Bremen (DE): Integrate HTA; 2016., making it easier for the service to plan actions and for the subjects involved therein to communicate⁷7. Mills T, Lawton R, Sheard L. Advancing complexity science in healthcare research: the logic of logic models. BMC Med Res Methodol. 2019;19(1):55. https://doi.org/10.1186/s12874-019-0701-4
https://doi.org/10.1186/s12874-019-0701-... . In this perspective, the logical model is a useful tool to develop, implement and evaluate complex processes, as it allows an overview that can identify key activities and outcomes⁸8. Rohwer AA, Booth a, Pfadenhauer L, Brereton L, Gerhardus a, Mozygemba K, et al. Guidance on the use of logic models in health technology assessments of complex interventions. Bremen (DE): Integrate HTA; 2016.,⁹9. PetersenD, Taylor EF, Peikes D. The Logic Model: the foundation to implement, study, and refine patient-centered medical home models. Rockville, MD: Agency for Healthcare Research and Quality; 2013. AHRQ Publication Nº 13-0029-EF..

Therefore, considering that the construction of these models for rehabilitation services provides an overview of the complex processes involved, generating relevant information for decision-making, this paper aims to build and validate a logical model for specialized care in CER. To achieve this, the research begins with the analysis of the work process and organizational issues in Rio Grande do Norte State.

METHODS

This is a descriptive methodological study, with a qualitative approach, developed in three stages: documentary analysis, focus groups and, finally, construction and validation of a logical model representing the functioning of CER⁸8. Rohwer AA, Booth a, Pfadenhauer L, Brereton L, Gerhardus a, Mozygemba K, et al. Guidance on the use of logic models in health technology assessments of complex interventions. Bremen (DE): Integrate HTA; 2016.,¹⁰10. Cassiolate MMMC, Gueresi S. How to develop logical model: roadmap for formulating programs and organizing evaluation. Brasília, DF: Intituto De Pesquisa Econômica Aplicada; 2010. (IPEA Technical Note; No. 6).. The research protocol was approved by the Research Ethics Committee of Faculdade de Ciências da Saúde do Trairi under CAAE no. 07082819.3.0000.5568. The study was conducted in accordance with the Helsinki Declaration, and the participants signed an informed consent form and authorized their voices to be recorded.

The first stage consisted in the study of ordinances, legislation and documents concerning the RCPD and the CER. The documentary analysis allowed us to understand the guidelines and standards applicable to the Health Network and the service that was to be evaluated. It also allowed the prior identification of key concepts useful for building the logical model¹⁰10. Cassiolate MMMC, Gueresi S. How to develop logical model: roadmap for formulating programs and organizing evaluation. Brasília, DF: Intituto De Pesquisa Econômica Aplicada; 2010. (IPEA Technical Note; No. 6)..

In the second stage, focus groups were organized with workers and managers to understand daily processes of the service¹¹11. Dall’agnol CM, Magalhães AMM, mano GCM, Olschowsky A, Silva FP. The notion of task in focus groups. Rev Gaucha Sick. 2012;33(1):186-90. https://doi.org/10.1590/S1983-14472012000100024
https://doi.org/10.1590/S1983-1447201200... . To optimize logistics issues while maintaining sample representativeness¹²12. Machado FCA, Souza GCA, Noro LRA. Proposition of indicators for oral health surveillance of adolescents. Cienc Collective Health. 2018;23(1):187-202. https://doi.org/10.1590/1413-81232018231.20842015
https://doi.org/10.1590/1413-81232018231... , we opted for a census sampling, with all CER from one state RCPD. For the convenience and insertion of researchers, nine CER from Rio Grande do Norte were chosen, which combined represent the state’s eight health regions. Each service was represented by a manager and a care professional, thus forming an equal composition. Professionals from different classes participated in the focus group: social service, nursing, physiotherapy, speech therapy, medicine, dentistry, psychology and occupational therapy.

The focus group sessions took place monthly as part of the RCPD Management Forum. Initially, only the manager of each service had been invited. However, at the request of the services themselves, workers who already regularly participated in the network management forums were included. In addition to the two service representatives (the manager and a care professional), two health professionals from outside the RCPD, with experience in health management and evaluation, took part in the focus groups.

The group was conducted by a team comprising a moderator and two observers, who took note of aspects concerning the non-verbal language of the participants (identified with badges) and the order and content of their testimonies¹¹11. Dall’agnol CM, Magalhães AMM, mano GCM, Olschowsky A, Silva FP. The notion of task in focus groups. Rev Gaucha Sick. 2012;33(1):186-90. https://doi.org/10.1590/S1983-14472012000100024
https://doi.org/10.1590/S1983-1447201200... . Throughout the focus groups, we sought to understand the following aspects in the participants’ testimonies: service demands, causes and consequences of demand, service objectives, target audience, resources, actions, products, results and factors that interfere with service performance¹⁰10. Cassiolate MMMC, Gueresi S. How to develop logical model: roadmap for formulating programs and organizing evaluation. Brasília, DF: Intituto De Pesquisa Econômica Aplicada; 2010. (IPEA Technical Note; No. 6)..

In all, five meetings were held between March and July 2019, each lasting an average 90 minutes. The audio was recorded with two digital recorders positioned at the ends of the tables. The testimonies were later transcribed, and the information categorized by content theme analysis¹¹11. Dall’agnol CM, Magalhães AMM, mano GCM, Olschowsky A, Silva FP. The notion of task in focus groups. Rev Gaucha Sick. 2012;33(1):186-90. https://doi.org/10.1590/S1983-14472012000100024
https://doi.org/10.1590/S1983-1447201200... , based on the theoretical framework of disability care, network care and health assessment.

The logical model was developed by the researchers based on the information collected in the previous steps, but without the presence of professionals associated with the CER¹⁰10. Cassiolate MMMC, Gueresi S. How to develop logical model: roadmap for formulating programs and organizing evaluation. Brasília, DF: Intituto De Pesquisa Econômica Aplicada; 2010. (IPEA Technical Note; No. 6).. For graphic presentation, an adapted version was built based on a proposal by Tamaki et al.¹³13. Tamaki EM, Tanaka OU, Felisberto E, Alves CKA, Drumond Junior M, Bezerra LCA, et al. Methodology of building a panel of indicators for monitoring and evaluation of SUS management. Cienc Collective Health. 2012;17(4):839-49. https://doi.org/10.1590/S1413-81232012000400007
https://doi.org/10.1590/S1413-8123201200... . The domains “mission”, “values” and “external factors” were added to the model.

The model was submitted to content validation in the last focus group with the CER representatives¹⁰10. Cassiolate MMMC, Gueresi S. How to develop logical model: roadmap for formulating programs and organizing evaluation. Brasília, DF: Intituto De Pesquisa Econômica Aplicada; 2010. (IPEA Technical Note; No. 6).. At this meeting, the group moderators presented the logical model in a multimedia projection and explained the domains included to the participants: demands, resources (inputs, financial resources and workforce), processes, products, results and external factors. The team then checked items and ideas contained in the model, domain by domain. Health service representatives expressed their opinions freely and suggested exclusions, inclusions or modifications to the allocation of items. The final version, to be considered validated, should be approved by consensus among the participants.

RESULTS

Created in 2012 as the main component of specialized care for people with disabilities, the CER are responsible for delivering rehabilitation and habilitation actions. These centers coexist with single-type rehabilitation services (mostly philanthropic), seeking to fill the care gap and promote comprehensive disability care in articulation way with other points of the RCPD¹⁴14. Malta DC, Stopa SR, Canuto R, Gomes NL, Mendes VLF, Goulart BNG, et al. Self-reported prevalence of disability in Brazil, according to the National Health Survey, 2013. Cienc Collective Health. 2016;21(10):3253-64. https://doi.org/10.1590/1413-812320152110.17512016
https://doi.org/10.1590/1413-81232015211... .

Specialized Rehabilitation Centers are part of a public health policy comprising pre-established agents, structures, processes and care goals¹⁵15. Munguba MC, Vieira ACVC, Porto CMV. From invisibility to social participation: health promotion in people with disabilities. Rev Bras Promoç. Health. 2015;28(4):463-6. https://doi.org/10.5020/18061230.2015.p463
https://doi.org/10.5020/18061230.2015.p4... . This policy, guided toward functioning and the biopsychosocial model, aims to offer rehabilitation services consistent with the principles and guidelines of the RCPD.

This policy is still being implemented, and it can be said that the mission of the CER is still poorly understood by both workers and users of the health system. In the day to day of the services, there are obvious difficulties regarding coverage, access, quality of care, therapeutic planning, human and material resources.

Considering that certain organizational work arrangements may prevent the comprehensiveness of care¹⁶16. Viana ALD, Bousquat AM, Arantes G, Negri Filho a, Medina MG. Regionalization and Health Networks. Cienc Collective Health. 2018;23(6):1791-8. https://doi.org/10.1590/1413-81232018236.05502018
https://doi.org/10.1590/1413-81232018236... , the aim was to develop a logical model of intervention that would answer the following questions: How do CER work? What are the elements of the Brazilian policy for disability care and how do they relate to one another? Do the objectives proposed in this policy move towards inclusion? What are the reasons that lead the rehabilitation policy to follow, or not, the RCPD guidelines?

The logical model lists the main topics of the organizational and working processes of CER, dividing them into six domains (Figure 1). It is worth noting that the model built from theoretical framework and discussions in the focus groups was approved by consensus, without modifications. Box 1 summarizes the themes and representative elements of the domain covered in the model.

During the focus groups, we sought to identify real difficulties and problems faced daily by managers and works, as well as causes, consequences and solutions to these problems. A summary of this information is given in Box 2.

DISCUSSION

The logical model is an important tool for decision making in health care because it allows a team to have an overview of the processes developed, whereby it can identify strengths and obstacles to obtaining the expected outcomes (whether products or results)⁸8. Rohwer AA, Booth a, Pfadenhauer L, Brereton L, Gerhardus a, Mozygemba K, et al. Guidance on the use of logic models in health technology assessments of complex interventions. Bremen (DE): Integrate HTA; 2016.. The model proposed here, based on a case study of services that comprise RCPD in Rio Grande do Norte, has been validated by professionals and is in line with international guidelines for care management and rehabilitation¹⁷17. Wade DT. What is rehabilitation? An empirical investigation leading to an evidence-based description. Rehabil Clin. 2020;34(5):571-83. https://doi.org/10.1177/0269215520905112
https://doi.org/10.1177/0269215520905112... and with CER standardization in Brazil⁵5. Ministry of Health (BR). Ordinance No. 793 of 24 April 2012. It establishes the Care Network for people with disabilities within the Unified Health System. Brasília, DF; 2012 [cited 2020 Jul 29]. Available from: https://bvsms.saude.gov.br/bvs/saudelegis/gm/2012/prt0793_24_04_2012.html
https://bvsms.saude.gov.br/bvs/saudelegi... ,²¹21. Ministry of Health (BR). Ordinance No. 1,060 of June 5, 2002. Approves the National Health Policy of the person with disabilities. Official Journal of the Union. 10 June 2002; Section 1: 21.,²²22. Brazil. Presidency of the Republic. Decree No. 6,949 of 25 August 2009. Promulgates the International Convention on the rights of Persons with disabilities and its Optional Protocol, signed in New York on 30 March 2007. Brasília, DF; 2009..

In comparison with other countries, the creation of policies and programs aimed at people with disabilities is still recent in Brazil. The National Health Policy for Persons with Disabilities²¹21. Ministry of Health (BR). Ordinance No. 1,060 of June 5, 2002. Approves the National Health Policy of the person with disabilities. Official Journal of the Union. 10 June 2002; Section 1: 21. and Ordinance No. 793/2012 are milestones in this process⁵5. Ministry of Health (BR). Ordinance No. 793 of 24 April 2012. It establishes the Care Network for people with disabilities within the Unified Health System. Brasília, DF; 2012 [cited 2020 Jul 29]. Available from: https://bvsms.saude.gov.br/bvs/saudelegis/gm/2012/prt0793_24_04_2012.html
https://bvsms.saude.gov.br/bvs/saudelegi... . This ordinance sets the tasks of CER: to provide proper diagnosis and treatment in a timely manner; to grant, adapt and maintain assistance technologies; to act in an articulated manner and as a matrix on the subject of disability with other points of the network; and to prevent deficiencies and further aggravation⁵5. Ministry of Health (BR). Ordinance No. 793 of 24 April 2012. It establishes the Care Network for people with disabilities within the Unified Health System. Brasília, DF; 2012 [cited 2020 Jul 29]. Available from: https://bvsms.saude.gov.br/bvs/saudelegis/gm/2012/prt0793_24_04_2012.html
https://bvsms.saude.gov.br/bvs/saudelegi... .

The services offered by the CER strengthen the rights won by people with disabilities over the years²¹21. Ministry of Health (BR). Ordinance No. 1,060 of June 5, 2002. Approves the National Health Policy of the person with disabilities. Official Journal of the Union. 10 June 2002; Section 1: 21.. These centers, as the logical model presented here shows, are in line with WHO recommendations to strengthen rehabilitation in health systems. The CER ensure community access to rehabilitation services, providing a multi-professional force and allocating financial resources to offer assistance devices and technologies to all who need them. They also provide adequate training on how to use them safely and effectively²²22. Brazil. Presidency of the Republic. Decree No. 6,949 of 25 August 2009. Promulgates the International Convention on the rights of Persons with disabilities and its Optional Protocol, signed in New York on 30 March 2007. Brasília, DF; 2009.. However, it is noteworthy that greater integration is needed between the different levels of care and services, taking into account the dynamic limitations and needs of individuals who, in addition to health, may require education, work, leisure and culture, among others²²22. Brazil. Presidency of the Republic. Decree No. 6,949 of 25 August 2009. Promulgates the International Convention on the rights of Persons with disabilities and its Optional Protocol, signed in New York on 30 March 2007. Brasília, DF; 2009.,²⁴24. Gulley SP, Rasch EK, Bethell CD, Carle AC, Druss BG, Howtrow AJ, et al. At the intersection of chronic disease, disability and health services research: a scoping literature review. Disabil Health J. 2018; 11 (2): 192-203. https://doi.org/10.1016/j.dhjo.2017.12.012
https://doi.org/10.1016/j.dhjo.2017.12.0... ,²⁵25. Alves MA, Ribeiro FF, Sampaio RF. Potential for change in health practices: the perception of workers of a Rehabilitation Network in (trans)training. Physio Pesq. 2016;23 (2):185-92. https://doi.org/10.1590/1809-2950/14945923022016
https://doi.org/10.1590/1809-2950/149459... .

The CER are recent services within the logic of the SUS²³23. Campos MF, Souza LAP, Mendes VLF. The care network of the Unified Health System for the health of people with disabilities. Interface (Botucatu). 2015;19(52):207-10. https://doi.org/10.1590/1807-57622014.0078
https://doi.org/10.1590/1807-57622014.00... , and it became clear in the focus group that some actions have not been consolidated yet. As an example, difficulties regarding global assessment and use of the International Classification of Functioning, Disability and Health (ICF) in therapeutic planning can be cited. Professionals also highlight the lack of social assistance, quality indicators and qualified hospital discharge indicators with timely referral to other services.

The ICF should be regarded as one of the pillars of the philosophy of disability care⁵5. Ministry of Health (BR). Ordinance No. 793 of 24 April 2012. It establishes the Care Network for people with disabilities within the Unified Health System. Brasília, DF; 2012 [cited 2020 Jul 29]. Available from: https://bvsms.saude.gov.br/bvs/saudelegis/gm/2012/prt0793_24_04_2012.html
https://bvsms.saude.gov.br/bvs/saudelegi... ,²²22. Brazil. Presidency of the Republic. Decree No. 6,949 of 25 August 2009. Promulgates the International Convention on the rights of Persons with disabilities and its Optional Protocol, signed in New York on 30 March 2007. Brasília, DF; 2009.. Its use in therapeutic planning allows producing data and feed information systems in a standardized way. With ICF, it is also possible to optimize the allocation of professionals and identify the necessary interventions for each case, directing the therapeutic process to human functioning, ceasing to consider solely the biological function that is temporarily or permanently impaired¹1. Heinemann Aw, Feuerstein M, Frontera WR, Gard AS, Kaminsky LA, Negrini S, et al. Rehabilitation is a global health priority. Arch Phys Med Rehabil. 2020;101(4):728-9. https://doi.org/10.1016/j.apmr.2019.08.468
https://doi.org/10.1016/j.apmr.2019.08.4... ,²⁰20. Stucki G, Rubinelli S, Bickenbach J. We need an operationalisation, not a definition of health. Disabled Rehab. 2020;42(3):442-4. https://doi.org/10.1080/09638288.2018.1503730
https://doi.org/10.1080/09638288.2018.15... ,²²22. Brazil. Presidency of the Republic. Decree No. 6,949 of 25 August 2009. Promulgates the International Convention on the rights of Persons with disabilities and its Optional Protocol, signed in New York on 30 March 2007. Brasília, DF; 2009.,²⁶26. Dantas DS, Correa AP, Buchalla CM, Castro SS, Castaneda L. Biopsychosocial model in health care: reflections in the production of functioning and disability data. Purple Physio. 2020; 33: e003321. https://doi.org/10.1590/1980-5918.033.ao21
https://doi.org/10.1590/1980-5918.033.ao... . Thus, the use of ICF shifts therapeutic planning from a biomedical perspective to a biopsychosocial and holistic model, contributing to a better design of the services and the development of public policies aimed at people with disabilities²2. Rauch A, Negrini S, Cieza A. Toward strengthening rehabilitation in health systems: methods used to develop a Who package of rehabilitation interventions. Arch Phys Med Rehabil. 2019;100(11):2205-11. https://doi.org/10.1016/j.apmr.2019.06.002
https://doi.org/10.1016/j.apmr.2019.06.0... ,²⁰20. Stucki G, Rubinelli S, Bickenbach J. We need an operationalisation, not a definition of health. Disabled Rehab. 2020;42(3):442-4. https://doi.org/10.1080/09638288.2018.1503730
https://doi.org/10.1080/09638288.2018.15... ,²⁶26. Dantas DS, Correa AP, Buchalla CM, Castro SS, Castaneda L. Biopsychosocial model in health care: reflections in the production of functioning and disability data. Purple Physio. 2020; 33: e003321. https://doi.org/10.1590/1980-5918.033.ao21
https://doi.org/10.1590/1980-5918.033.ao... .

As for discharge, the focus group participants considered it a problematic moment in the CER routine. To reverse this scenario, disability care needs to articulate different services and levels of attention²⁷27. Machado WCA, Pereira JS, Schoeller SD, Júlio LCT, Martins MMFPS, Figueiredo NMA. Comprehensiveness in the care network regarding the care of the disabled person. Context Inferm Text. 2018; 27(3): e4480016. https://doi.org/10.1590/0104-07072018004480016
https://doi.org/10.1590/0104-07072018004... . Specialized Rehabilitation Centers need to be seen as places for specialized attention, and not as the only service for people with disabilities. They must function as the matrix²³23. Campos MF, Souza LAP, Mendes VLF. The care network of the Unified Health System for the health of people with disabilities. Interface (Botucatu). 2015;19(52):207-10. https://doi.org/10.1590/1807-57622014.0078
https://doi.org/10.1590/1807-57622014.00... to coordinate care actions and raise awareness of society and other services about their role in society, in order to facilitate the understanding of those involved in care and to optimize access and referrals. When this does not happen, communication channels between workers and services become inefficient, and failure to understand the role of CER within the network can result in underutilization of their actions²⁷27. Machado WCA, Pereira JS, Schoeller SD, Júlio LCT, Martins MMFPS, Figueiredo NMA. Comprehensiveness in the care network regarding the care of the disabled person. Context Inferm Text. 2018; 27(3): e4480016. https://doi.org/10.1590/0104-07072018004480016
https://doi.org/10.1590/0104-07072018004... ,²⁸28. Machado WCA, Silva VM, Silva RA, Ramos RL, Figueiredo NMA, Castelo Branco SEM, et al. Hospital discharge of patients with disabling neurological injury: necessary referrals to rehabilitation. Cienc Collective Health. 2016;21(10):3161-70. https://doi.org/10.1590/1413-812320152110.17232016
https://doi.org/10.1590/1413-81232015211... .

The lack of an evaluation culture permeates the Brazilian health system²⁹29. Pryor W, Newar P, Retis C, Urseau I. Compliance with standards of practice for health-related rehabilitation in low and middle-income settings: development and implementation of a novel scoring method. Disab Rehabil. 2019;41(19):2264-71. https://doi.org/10.1080/09638288.2018.1462409
https://doi.org/10.1080/09638288.2018.14... . Besides the lack of internal evaluation of the quality of processes and services delivered, there is a lack of professionals working in rehabilitation. The uneven distribution of health workers and services aggravate the situation of assistance to people with disabilities, which has shown quality below ideal²⁹29. Pryor W, Newar P, Retis C, Urseau I. Compliance with standards of practice for health-related rehabilitation in low and middle-income settings: development and implementation of a novel scoring method. Disab Rehabil. 2019;41(19):2264-71. https://doi.org/10.1080/09638288.2018.1462409
https://doi.org/10.1080/09638288.2018.14... ,³⁰30. Bright T, Wallace S, Kuper H. A systematic review of access to rehabilitation for people with disabilities in low - and middle-income countries. Int J Environ Res Public Health 2018;15 (10): E2165. https://doi.org/10.3390/ijerph1510216
https://doi.org/10.3390/ijerph1510216... .

Among the external factors interfering with the performance of the service, criticism of the way CER are is a central issue. When referral services are authorized for only some types of disability (albeit based on territorial diagnosis), attention becomes fragmented as it disregards various disabilities. The health needs of people are not standardized and can vary within the same health territory, so that it would be necessary to relax regulations for each territory to adapt the service to its reality and, at the same time, ensure access to rehabilitation services in a timely manner, without making patients have to travel long distances²²22. Brazil. Presidency of the Republic. Decree No. 6,949 of 25 August 2009. Promulgates the International Convention on the rights of Persons with disabilities and its Optional Protocol, signed in New York on 30 March 2007. Brasília, DF; 2009.,²⁹29. Pryor W, Newar P, Retis C, Urseau I. Compliance with standards of practice for health-related rehabilitation in low and middle-income settings: development and implementation of a novel scoring method. Disab Rehabil. 2019;41(19):2264-71. https://doi.org/10.1080/09638288.2018.1462409
https://doi.org/10.1080/09638288.2018.14... .

In addition, specialized care services are concentrated in capitals, metropolises and regional centers²³23. Campos MF, Souza LAP, Mendes VLF. The care network of the Unified Health System for the health of people with disabilities. Interface (Botucatu). 2015;19(52):207-10. https://doi.org/10.1590/1807-57622014.0078
https://doi.org/10.1590/1807-57622014.00... . This concentration forces people with disabilities to travel long distances to seek care, which goes against the WHO recommendation that rehabilitation services should be available as close to communities as possible, including rural communities²³23. Campos MF, Souza LAP, Mendes VLF. The care network of the Unified Health System for the health of people with disabilities. Interface (Botucatu). 2015;19(52):207-10. https://doi.org/10.1590/1807-57622014.0078
https://doi.org/10.1590/1807-57622014.00... ,²⁶26. Dantas DS, Correa AP, Buchalla CM, Castro SS, Castaneda L. Biopsychosocial model in health care: reflections in the production of functioning and disability data. Purple Physio. 2020; 33: e003321. https://doi.org/10.1590/1980-5918.033.ao21
https://doi.org/10.1590/1980-5918.033.ao... ,³⁰30. Bright T, Wallace S, Kuper H. A systematic review of access to rehabilitation for people with disabilities in low - and middle-income countries. Int J Environ Res Public Health 2018;15 (10): E2165. https://doi.org/10.3390/ijerph1510216
https://doi.org/10.3390/ijerph1510216... .

Although based on a study conducted in only one state of the Brazilian federation, the model presented here was shown to be in line with national and international theories and standards. Nevertheless, its use in services in other regions should consider the context of each service. In addition, future studies should include the perceptions of users in addititon to the perceptions of workers and managers. This approach can promote the protagonism of people with disabilities, as recommended by the International Convention on the Rights of Persons with Disabilities²³23. Campos MF, Souza LAP, Mendes VLF. The care network of the Unified Health System for the health of people with disabilities. Interface (Botucatu). 2015;19(52):207-10. https://doi.org/10.1590/1807-57622014.0078
https://doi.org/10.1590/1807-57622014.00... .

A limitation of this study was the lack of care professionals in some focus groups due to schedule conflicts and other appointments. However, we believe that this limitation did not have a significant impact on the results of the study, since the model was validated without corrections. In addition, all participants were indicated by the services themselves and had previous experience with CER.

By comparing the validated model - which represents the ideal functioning of the services - with the local reality, workers and managers will be able to evaluate the services in which they operate, identifying potentialities and challenges. The logical model can thus work as a management tool for knowing the implementation of the service, for aiding decision-making in health care and, ultimately, favoring the planning of care actions for people with disabilities.

In addition, having identified the crucial points of the service, the model can be useful for setting up performance indicators applicable to CER, thus helping in the development of an evaluation culture in the services, either by internal or external processes of quality evaluation.

The logical model and the identification of the problems associated with the organizational structure of the CER show that the rehabilitation policy for people with disabilities is still being implemented in Brazil. Although such a policy is designed to be in line with the most up-to-date care guidelines, in reality there are obstacles in the access, patient inflow and the actions provided. It is therefore necessary to reorient the service toward complying with the guidelines of comprehensive care, focusing on human functioning, and achieving the expected results: improving quality of life and promoting social inclusion of people with disabilities.

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