Abstract

This study describes the history, methodology and evolution of the Forum of NonProfit Long-Term Care Facilities for Older Adults (LTCF - Fórum das Instituições Filantrópicas de Longa Permanência para Idosos) of the São Paulo Metropolitan Region, Brazil, and contextualizes its path towards the normative advances that regulate these institutions nowadays. By reading and analyzing the reports of the meetings that occurred between the years 1999 and 2015 a descriptive, qualitative and retrospective study was performed. We observed that the network articulation provided by the meetings during the 16 years of activity can help with the organization, planning and maintenance of LTCFs, improving the quality of the services in accordance to the current legislation, promoting the approximation and engagement of partners in the search for professionalism of long-term institutional care and excellence in care for older adults, and on the improvement and qualification of professionals, processes and institutional protocols.

Keywords:
Long-term Care Facilities for Older Adults; Collaborative Networks; Nonprofit Organizations; Forum; Management

Introduction

The number of dependent older adults with specials needs who require long-term care is increasing. The long-term care facilities (LTCF) in Brazil, are the most used alternative for care when the family is unable to provide home care. The care for the institutionalized older adult is complex due to the prevalence of chronic diseases and functional limitations. LTCFs must provide shelter, food, leisure and social interactions, in addition to primary health care, forwarding the resident to medical and hospital services when necessary. Thus, these facilities can no longer be qualified as a social assistance equipment only, the social and health hybrid model is recommended (Camarano, 2010CAMARANO, A. A. (Org.). Cuidados de longa duração para a população idosa: um novo risco social a ser assumido? Rio de Janeiro: Ipea, 2010.; Paula et al., 2014PAULA, R. C. C. et al. Dimensionamento de pessoal de enfermagem em instituições de longa permanência para idosos: proposta de número de horas. Revista Enfermagem Profissional, Rio de Janeiro, v. 1, n. 2, p. 398-412, 2014.).

In Brazil, the first institutions designed to care for the older adults who served the country and those who needed shelter to age, date from the end of the 17^th century. Hospitals also provided services to poor and excluded people, as well as orphans and sick persons. In Rio de Janeiro, one of the first institutions for older adults was created in 1890 (Novaes, 2003NOVAES, R. H. L. Os asilos de idosos no Estado do Rio de Janeiro: Repercussões da (não) integralidade no cuidado e na atenção à saúde dos idosos. 2003. Dissertação (Mestrado em Saúde Coletiva) - Instituto de Medicina Social, Universidade Estadual do Rio de Janeiro, Rio de Janeiro, 2003.).

Since the first years after the Discovery charity groups exist in Brazil. Reference in hosting and caring for poor people, the Santa Casa de Misericórdia de Santos was constructed in 1543. Charitable entities maintained (and in some cases still maintain) the meaning of care as a gesture of goodwill and charity to the next (Carvalho, 2008CARVALHO, G. F. A assistência social no Brasil: da caridade ao direito. Monografia (Bacharelado em Direito) - Pontifícia Universidade Católica do Rio de Janeiro, Rio de Janeiro, 2008.). The care for the repercussions of poverty and misery were isolated actions of charity for the poor and disadvantaged during the 18th century. Initiatives coming from religious institutions provided care, shelter, clothes and food to orphans, older and sick people at places constructed and maintained by religious institutions and by wealthy people (Escorsim, 2008ESCORSIM, S. M. A filantropia no Brasil: entre a caridade e a política de assistência social. Revista Espaço Acadêmico, Maringá, n. 86, p. 1-8, 2008.; Nascimento, 2013NASCIMENTO, I. M. Proteção social aos idosos: um desafio para o serviço social da Promotoria de Justiça de Defesa dos Direitos Humanos do Ministério Público do Rio Grande do Sul. Revista de Graduação da PUC-RS, Porto Alegre, v. 6, n. 1, p. 23, 2013.).

The National Council of Social Service (Conselho Nacional de Serviço Social) was created only in 1938, during the government of Getúlio Vargas, however, a conservative logic of social assistance was taken in its philanthropic aspect with the creation and dissemination of the Brazilian Legion of Assistance (Legião Brasileira de Assistência) (Carvalho, 2008CARVALHO, G. F. A assistência social no Brasil: da caridade ao direito. Monografia (Bacharelado em Direito) - Pontifícia Universidade Católica do Rio de Janeiro, Rio de Janeiro, 2008.; Escorsim, 2008ESCORSIM, S. M. A filantropia no Brasil: entre a caridade e a política de assistência social. Revista Espaço Acadêmico, Maringá, n. 86, p. 1-8, 2008.).

The recognition of social assistance as one of the pillars of social security and as a public policy of social protection is guaranteed by the Federal Constitution of 1988, by the Organic Law of Social Assistance (Loas - Lei Orgânica da Assistência Social) in 1993, and the National Policy for Social Assistance (Política Nacional de Assistência Social) in 2004, legally consolidated social assistance as a right, allowing the social inclusion and emancipation by ensuring access to education, health, housing, leisure, transport and other rights (Borba, 2011BORBA, R. D. C. F. Um estudo sobre a estruturação da rede de proteção social voltada à população idosa no município de Vitória. 2011. Dissertação (Mestrado em Política Social) - Centro de Ciências Jurídicas e Econômicas da Universidade Federal do Espírito Santo, Vitória, 2011.).

Despite the political advances and the legal framework, traditional non-governmental charity entities still exist, they idealize their actions grounded by the moral duty and guided by a nonprofit logic and by charity and voluntarism, these institutions do not aim to achieve social rights. Despite the advancement of management tools of processes, people and resources in the 21st century, these entities have no strategic planning that clearly indicates its functions, benefits and beneficiaries, budget, criteria for application and distribution, as well as their way of management and control, reinforcing the nonprofit and clientelist character when conducting the policy at the expense of the strengthening assistance as a social right and an integral policy of social security (Boschetti, 2001BOSCHETTI, I. Assistência social no Brasil: um direito entre originalidade e conservadorismo. Brasília, DF: Grupo de Estudos e Pesquisas em Seguridade Social e Trabalho, 2001.).

Reports of abuse and deaths among residents of an asylum institution in Rio de Janeiro, Brazil, in 1996, brought attention to the rights of older adults living in institutions. In the state of São Paulo, the Group of Special Performance for the Protection of Older Adults (Gaepi - Grupo de Atuação Especial de Proteção ao Idoso), the class councils, and especially the Regional Council of Nursing (Coren - Conselho Regional de Enfermagem), and the Health Surveillance (Visa - Vigilância Sanitária) started to systematically inspect the institutions that focused on charity and shelter for poor older adults with no family (São Paulo, 1997).

Due to the demands of this inspection some managers and nurses of traditional nursing homes in the São Paulo metropolitan region started to meet in order to seek alternatives and to share challenges and experiences, creating the Group of Nonprofit Entities currently self-named as Forum of the LTCFs.

The objective of this study is to describe the history, the work methodology and the evolution of the Forum of the LTFCs of São Paulo in its 16 years of existence; to identify benefits and difficulties; and to contextualize the trajectory of the group facing the normative advances currently regulating the facilities.

Theoretical Framework

The Portuguese word asilo, derived from the Greek word ásylos and named in Latin as asylum, is defined as a social assistance home where poor and helpless people such as beggars, abandoned children, orphans and older people are sheltered. Thus, relating to the idea of shelter and protection regardless of social or political character and regardless of specific physical and/or mental dependencies. Due to the generic nature of this definition, other terms were created to describe places of care for the elderly, such as shelter, home, nursing home, geriatric clinic and ancianato (Araújo; Souza; Faro, 2010ARAÚJO, C. L. O.; SOUZA, L. A.; FARO, A. C. M. Trajetória das instituições de longa permanência para idosos no Brasil. História da Enfermagem, Brasília, DF, v. 1, n. 2, p. 250-262, 2010.).

Among the laws to regulate LTCFs, the Ministry of Health issued the Ordinance No. 822/1989 (repealed by Ordinance No. 1,868, of October 10, 2005), to approve regulations and standards for nursing homes, geriatric clinics and other institutions for older adult care (Brasil, 1989). The Ministry of Social Welfare (MPAS - Ministério da Previdência Social) issued the Ordinance No. 73/2001, with standards for the functioning of care services to older adults in Brazil, dividing them into the modalities of: temporary residence, adult day care, home care, nursing home, among others (Brasil, 2001). In 2003, the Older Adult Statute defined that the Public Prosecution Office, the Visa and the Older Adult Council are responsible for inspecting LTCFs (Brasil, 2003; Camarano, 2010CAMARANO, A. A. (Org.). Cuidados de longa duração para a população idosa: um novo risco social a ser assumido? Rio de Janeiro: Ipea, 2010.).

Due to the variety of terms used to designate the different residences that offer long-term care for older adults, the Brazilian Society of Geriatrics and Gerontology (SBGG - Sociedade Brasileira de Geriatria e Gerontologia) adopted the term initially proposed by Tomiko Born: Long-Term Care Facility, which emphasizes the hybrid function of these institutions that no longer have only welfare-oriented character, but also providing health care. The term designates organizations for full institutional care, whose target audience are people of 60 years or older, with dependence or not, with no conditions to stay with the family or in their home. These facilities must provide social, medical, psychology, nursing, physiotherapy, occupational therapy and dentistry services. (Camarano, 2010CAMARANO, A. A. (Org.). Cuidados de longa duração para a população idosa: um novo risco social a ser assumido? Rio de Janeiro: Ipea, 2010.; SBGG, 2003).

In 2005, the National Agency of Health Surveillance (Anvisa - Agência Nacional de Vigilância Sanitária), defined through the Joint Board Resolution (RDC - Resolução da Diretoria Colegiada) No. 283, that LTCFs are governmental or non-governmental institutions, of residential character, aimed at the collective housing of people with 60 years or more, with or without family support, in condition of freedom, dignity and citizenship (Brasil, 2005).

Law No. 12,101/2009 modified the legal regime of granting the certification of Charitable Entities of Social assistance, the document required to request exemptions from social security contributions. After this, the granting and renewal of the certification are responsibility of the ministries of Social Development, of Combat to Hunger, Health and Education, according to the performance of each entity (Brasil, 2009).

Nowadays, the partnerships between Social Assistance and entities can only occur in state and municipal levels and on the Federal District after a resolution of the Board of Social Assistance, according to the article 7 of the Decree No. 1,605, of 1995, and in accordance to the Loas, through the guideline of the single command of the actions in each sphere of government, managing the service provider network is the authority of the municipality and, in the case of special protection of the state governments (therefore, of LTCFs). Thus, the agreements within the framework of the National Fund of Social Assistance (Fundo Nacional de Assistência Social) cannot be executed directly with entities, but only with state, municipal and Federal District governments (CNAS, 2012).

The third millennium came accompanied by historical events that transformed the social scenario of humanity. Information technologies brought innovations that reshaped the material base of society in a fast pace. Several economies started to maintain global interdependence, presenting a new form of relationship between economy, state and society, in a system of variable geometry. Capitalism itself is going through a deep restructuring process, characterized by greater management flexibility, decentralization and network organization of companies, both internally and in its relations with other companies (Castells, 2003CASTELLS, M. A sociedade em rede. 7. ed. São Paulo: Paz e Terra, 2003.).

According to Guzmán, Huenchuan and Oca (2003GUZMÁN, J. M.; HUENCHUAN, S.; OCA, V. M. Redes de apoyo social de las personas mayores: marco conceptual. Notas de Población, Santiago do Chile, v. 30, n. 77, p. 35-70, 2003.), the informal network is a primary support system integrated to provide and receive objects, services, social and emotional support, considered by the recipient and by the provider as important. Castells (2003CASTELLS, M. A sociedade em rede. 7. ed. São Paulo: Paz e Terra, 2003.) defines network as the set of interconnected nodes, capable of unlimited expansion, they intercommunicate and share similar codes, such as values or performance objectives.

The network is a non-linear structure, decentralized, flexible, dynamic and without limits, is established by horizontal relations of cooperation (Tomaél; Alcará; Chiara, 2005TOMAÉL, M. I.; ALCARÁ, A. R.; CHIARA, I. G. D. Das redes sociais à inovação. Ciência da Informação, Brasília, DF, v. 34, n. 2, p. 93-104, 2005.). According to Cunha and Passador (2007CUNHA, J. A. C.; PASSADOR, J. L. Alianças estratégicas de organizações: o aprendizado institucional na formação de redes. Revista Eletrônica de Ciência Administrativa, Campo Largo, v. 6, n. 1, p. 1-16, 2007.), regardless of who starts these relations, creating cultures and local initiatives of cooperation occurs more solidly when the phenomenon can generate bonds with links of trust and ethics in the same measure, on the counterpart and on the growth spiral.

Forums are spaces or debate scenarios where the representations about a public policy or collective problem, as well as the most adequate instruments and strategies to analyze them are germinated and discussed (Fouilleux, 2011FOUILLEUX, E. Analisar a mudança: políticas públicas e debates num sistema em diferentes níveis de governança. Estudos Sociedade e Agricultura, Rio de Janeiro, v. 19, n. 1, p. 88-125, 2011.).

For Cruz, Malik and Quandt (2008CRUZ, J. A. W.; MARTINS, T. S.; QUANDT, C. O. Redes de cooperação: um enfoque de governança. Revista Alcance, Itajaí, v. 15, n. 2, p. 190-208, 2008.), various organizations, members of civil society and social movements participate in forums. The guidelines are collectively defined beforehand, stimulating the presentation and participation of the members. Forums promote the involvement of the communities and organizations with the reality and with common problems, in addition to the discussion of new projects and the sharing good practices and achievements.

Participation in forums requires the provision of institutional resources, such as the access to discussions, voting power, political, human, financial and discursive resources, understood as the analytical and forecasting capacity named by Fouilleux (2011FOUILLEUX, E. Analisar a mudança: políticas públicas e debates num sistema em diferentes níveis de governança. Estudos Sociedade e Agricultura, Rio de Janeiro, v. 19, n. 1, p. 88-125, 2011.) as “policy intelligence”, understood as the capacity of expertise and production of categories, of decoding reality, adapting the speech to the audience and the ability of building partnerships and strategic alliances (Alves et al., 2013ALVES, J. N. et al. Confiança, aprendizagem e conhecimento nos relacionamentos interorganizacionais: diagnóstico e análise dos avanços sobre o tema. Revista Eletrônica de Administração, Porto Alegre, v. 76, n. 3, p. 709-737, 2013.).

Methodology

We performed a retrospective study, of descriptive and qualitative character, through the analysis of the records of the minutes of the forum since the beginning of the group, in 1999 until 2015. The content of the minutes was distributed in a spreadsheet containing the year of meetings, number and name of the entities and other types of institutions present; the subject discussed; extraordinary discussions and the benefits of the meetings.

After the tabulation, content analysis as proposed by Bardin (2011BARDIN, L. Análise de Conteúdo. São Paulo: Edições 70, 2011.) was performed, composed by the pre-analysis, in which the selection of sampling was done; by the exploration of the material that generated the categorization as a response to the context analyzed; and the treatment of the results through inference and interpretation.

Results and discussion

The initiative to create the group started in September 1999, with five nonprofit organizations. Around this period the group worried about the definition of their nature, agreeing that nursing homes could not be inspected with the same requirements of hospitals. The participants began to share documents, forms, and bibliographies and to invite entities of a similar nature to compose the group. The meetings happened every month, changing location and favoring the visit and recognition of the environment of the entities involved.

At the end of 2000, the group incorporated a university teacher, a social worker specialized in Gerontology and representative of the National Forum of Gerontology Institutions (Fórum Nacional de Instituições Gerontológicas) of the SBGG and two nurses from private hospitals invited occasionally to discuss matters related to Coren. In 2001 the group was formed by 15 entities and only two of these entities sought profit.

The meetings were preceded by bodily experiences for integration and mental and body relaxation. After this, discussions in subgroups on priority topics were held, sharing difficulties, adopted strategies and referrals. The current dynamic of the meetings was established in 2003. In addition to the reports and usual discussions, an expert is invited to speak on a previously defined theme. According to Zouain, Alves and Pieranti (2006ZOUAIN, D. M.; ALVES, J. A. B.; PIERANTI, O. P. Relatório final de atividades do Fórum de Discussão Permanente de Políticas de Esporte. Revista de Administração Pública, Rio de Janeiro, v. 40, n. 4, p. 731-40, 2006.), a similar methodology was adopted by the members of a permanent discussion forum in sports.

The group grew and extended the invitation to other equipment and bodies, such as universities, class councils, professionals specialized in geriatrics and gerontology, etc. At the last meeting of each year, the group promotes the self-assessment about the benefits, requirements yet to be covered, expectations and planning for the following year.

Between 1999 and 2015, 155 meetings were held and the presence of 80 LTCFs was registered, most of them private and nonprofit, two public and 15 private. Forty-four organizations were present, among universities, class councils, municipal departments, non-governmental organizations, Public Prosecution Office, Visa, SBGG. Among the 80 LTCFs, 21 attended just one meeting, the investigation by members of the forum of the reasons for this occurrence is required. Considering that the invitation is done monthly for every registered LTCF and that the subject is sent previously, a hypothesis is that some entities only attended the meetings of self-interest, such as matters related to inspection, legislation and funding resources, neglecting the other purposes of the forum.

Participants generally do not occupy board or management positions and have professional training in the areas of social work, nursing, psychology, physiotherapy and occupational therapy; eventually, there are also caregivers. We noted two situations in the records of the minutes: greater participation of associates of the LTCF hosting the meeting and of professionals with technical training closely linked to the monthly theme.

There is rotation in the participation of LTCFs and of professionals in the meetings, due to the termination or impossibility of attending the same associates at meetings. Such situation can occur because the e-mail addresses are non-institutional but of the associate, making the communication difficult in the event of a termination. This movement can limit the practical implementation of the protocols, of the incorporation of successful fundraising experiences or activities/strategies adopted for human resources (HR) and residents.

After content analysis seven categories of subjects discussed at the meetings were obtained: training; exchange and collective construction of forms, protocols, manuals and documents; survey and sharing of difficulties with residents, HR, Coren and Visa; exchange of successful experiences of fundraising; adjustment and positioning of the entities under the legislation or the absence of it; expansion and strengthening of the group; and benefits pointed by the participants. The categories are presented and discussed as follows.

Training

Perception of the group as a space of training occurred during the first meetings without prior establishment of strategies, which initially resulted in reading and discussing texts, laws and bibliographies used by the professionals of the entities. With the expansion of the group some alternatives proposed by members were tested.

In 2001, priority themes for the institutional routine were elected and mediated by experts at the next meeting. In the end, the intention was to transform the contents into a leaflet with practical tips, as well as the systematization of actions. The institutional organization and the verification of the functional profile of the residents for HR sizing were cited as examples. Another strategy was the recommendation to read bibliography on the theme prior to the meetings and to discuss in subgroups, with compilation of focal points and questions. After the systematization of information an expert would be invited to speak to the group. The product of this process would be transformed into training materials.

During the 16 years of existence of the group the recurrence of certain themes was noted, sometimes due to the rotation of the participants, or due to the persistence of difficulties or the lack of legislation or technical legislation to direct the actions, such as the question of hiring caregivers of older adults or how the inspection would be performed by class councils and by Visa.

The most discussed subjects were the preparation of internal manuals and protocols; norms of technical operation; management of volunteers; fundraising; the role of nursing and Standardization of Nursing Care (SAE - Sistematização da Assistência em Enfermagem); the performance of Coren; public policies for older adults; labor rights and legislation; role of caregivers and regularization of the profession.

Regarding technical training, the following were discussed: dementia syndromes; palliative care; performance of the nutrition, physiotherapy, pharmacy and geriatrics team; oral health; alcoholism among older adults; behavior changes; sexuality; prevention of falls; mechanical restriction/restraint and the social network of support for older adults.

Regarding bodies of support to LTCFs, debates were done on the action of municipal and state councils of older adults, of agreements established with city halls and the certifications foreseen on Law No. 12,101/2009 (commonly called “Nonprofit Act”) and on the Municipal Board of Social Assistance. Considering the internal difficulties experienced by several LTCFs, lectures on certain subjects were given on the contract of provision of services between the older adult/family and the LTCF; ambience and aging; caregiver stress; humanized care for the older adult and the family; reports of good practices; and the possibility of the formation of the association of LTCFs as an initiative to make the activities of the group official.

Exchange and collective construction of forms, protocols, manuals and documents

The initial concern of the group was to establish classifications for internal procedures and recording in charts that would not characterize the institution as a hospital, since the entity is the residence of the older adult, who receives aid for everyday activities, and not only health care. The participants brought forms and instruments for discussion and adoption of appropriate technical terms, aiming for a more directed understanding by regulatory agencies, such as the class councils, these agencies applied the same requirements of hospitals.

There were also meetings on recruitment and selection processes, reading and presentation of laws, view of terms of adhesion of volunteers, training, procedures adopted, administrative routines. The meetings were important for the adjustments to be instituted, highlighting the role of the participants in the identification of irregularities and on the proposal suggestions and adjustments through training, exchange of experiences or adoption of procedures already used with success.

With the help of technicians, the participants reached a consensus on the definition of a manual of LTCFs in 2011, presenting the goal, target audience, content and formatting. We found interesting to note how the concepts are similar to the scientific literature (Derntl, 2005DERNTL, A. M. Quem administra as instituições de longa permanência para idosos? Portal do envelhecimento, 2005. Disponível em: <Disponível em: http://bit.ly/2iB9Hbg >. Acesso em: 17 abr. 2016.
http://bit.ly/2iB9Hbg... ; Santos et al., 2008SANTOS, S. S. C. et al. O papel do enfermeiro na instituição de longa permanência para idosos. Revista de Enfermagem UFPE, Recife, v. 2, n. 3, p. 291-299, 2008.; Watanabe, 2009WATANABE, H. A. W. Instituições de longa permanência para idosos. In: BARROSO, A. E. S. (Coord). Rede de atenção à pessoa idosa. São Paulo: Secretaria Estadual de Assistência e Desenvolvimento Social: Fundação Padre Anchieta, 2009. p. 11-21.).

There were opportunities for the discussion of protocols for the prevention of falls; mechanical restriction/restraint; use of the fridge; manual on the working of the laundry and cleaning; nursing routines and procedures. The debate started from instruments used, with the study of possibilities for adaptation and implementation or development of a single protocol to be adopted by LTCFs, corroborating to Alves et al. (2013ALVES, J. N. et al. Confiança, aprendizagem e conhecimento nos relacionamentos interorganizacionais: diagnóstico e análise dos avanços sobre o tema. Revista Eletrônica de Administração, Porto Alegre, v. 76, n. 3, p. 709-737, 2013.) on the synergy of learning through the targeting of rules and practices of the participating organizations of a network.

Survey and sharing of difficulties with residents, HR, Coren and Visa

Participants identified various difficulties regarding regulatory agencies, class councils and Visa. Even nowadays the main challenge is adapting to the requirements of these institutions: recruitment of HR and adaptations of the environment, security and space due to the lack of financial resources to do so, given the nonprofit nature of LTCFs.

During the meetings, lawyers and professors emphasized the understanding that Coren has the function of inspecting the professional practice of the nursing staff, with no legal authority on the institution. There are reports on the minutes of this council conducting inspections in various participating entities and requesting the hiring of nurses, the implementation of SAE, among other requests. In 2001, the group allied to the SBGG to request support, the SBGG was already discussing the theme of residences for older adults in congresses and scientific meetings on the absence of single naming and standardization to this mode of care for older adults.

Between 1999 and 2005, the importance of organization and readjustment of the entities due to the requirements and notifications of regulatory agencies was noted. Strengthened by the discussions and partnerships with universities and the scientific community the LTCFs faced Coren, justifying activities and routines and improving the quality of the interventions performed by this council, which started to understand the form of care offered, acting more like a partner and guide of technical procedures.

Corroborating to this, the Manual of Inspection of the Federal Council of Nursing (Cofen - Conselho Federal de Enfermagem) sets in its first article that “the system of inspection of the professional practice of nursing is based on a conception of the educational process, to stimulate the ethical values and the appreciation of the work process in nursing” (Cofen, 2011), contrasting to the purely punitive nature, that once prevailed within this council.

A group of nurses was created as a result of the meetings of the forum, composed by nurses working in entities, representatives of Coren and teachers to discuss specific themes of the category, such as the implementation of SAE, security protocols for the resident and the definition of necessary resources for care at LTCFs, which are different from the needs of hospital nursing. Representatives of Coren began to attend meetings of the forum regularly, in addition to contributing actively in the discussions of the group of nurses, adding technical and legislative knowledge and, on the other hand, better understanding the structure and functioning of LTCFs.

Exchange of successful experiences of fundraising

Fundraising is a recurring theme in the meetings due to its importance to the financial survival of the entities. They share public notices from government bodies for the registration of programs and projects, development programs offered by non-governmental organizations, partnership opportunities with private companies that have social responsibility programs, with pastorals of the Catholic Church, with groups of other religions and even with international foundations.

Law No. 12,685/2007 (São Paulo, 2007) created the Program of Stimulus to Tax Citizenship of the State of São Paulo (Programa de Estímulo à Cidadania Fiscal do Estado de São Paulo), which provides benefits to nonprofit social assistance and health organizations. To take advantage of the credits granted by the Nota Fiscal Paulista Program¹1 The Nota Fiscal Paulista Program is an incentive program of the state of São Paulo in which people can ask for their Social Security Number to be included on receipts and these receipts can either be donated as credits to certain institutions or rebated later in the year. and participate in the raffles, the entities must be registered in the respective secretariats and with the legal documentation updated. After receiving the donation of the receipts, the organization must register them in the system of the Secretariat of Finance. The credits are passed on to the organization once every semester. Although it is a laborious process, which demands hours of typing and human resources, there are organizations in the group that have volunteers to take care of the steps of the process and find in this program a significant portion of their financial resources. On the other hand, there are LTCFs that point to a small financial return in relation to the necessary workforce, corroborating to Creutzberg, Gonçalves and Sobottka (2007CREUTZBERG, M.; GONÇALVES, L. H. T.; SOBOTTKA, E. A. A sobrevivência econômica de instituições de longa permanência para idosos empobrecidos. Revista Latino Americana de Enfermagem, Ribeirão Preto, v. 15, 2007. Número especial.) and Freire, Mendonça and Costa (2012FREIRE, F. S.; MENDONÇA, L. H.; COSTA, A. J. B. Sustentabilidade econômica das instituições de longa permanência para idosos. Saúde em Debate, Rio de Janeiro, v. 36, n. 95, p. 533-543, 2012.).

Some LTCFs have telemarketers hired or working as volunteers to pick up donations, this is their main financial source. The calls are performed through databases and the operators are trained about the purpose of the calls, forms of collection, thanking, accountability and maintenance of the donors. According to the Study Group on the Third-Sector (Grupo de Estudos do Terceiro Setor) and the United Way Canada (2002), a good donation program requires specific strategies to identify potential donors, well trained teams to ask and techniques of thanking and gratitude to the donors.

The meetings provided the establishment of relation and cooperation networks between organizations that divulge the need for HR recruitment, scientific or charitable events, fundraising bazaars, selling products made by residents, sales of books or technical manuals, availability of vacancies for independent older adults and sharing donations with other institutions when they realize that their inputs will exceed the consumption.

Adjustment and positioning of the entities under the legislation or the absence of it

Questionings about the hiring of caregivers of older adults are pointed since the beginning of the meetings, in some cases, personal caregivers, who, in 2000, would need to be under the supervision of medics due to the prevention of Coren that these professionals are oriented by the nursing staff. Currently, despite the regulation of the profession and the recognition of the caregiver as a professional category in the Brazilian Classification of Occupations, there are still restrictions of this council on the participation of caregivers in the team.

Starting in 2000, the group accompanied the efforts of the scientific community to contribute to the establishment of minimum standards of operation of LTCFs and of a single assessment instrument, built and tested by technicians. The current legislation for LTCFs was instituted only in 2005 - RDC No. 283 from Anvisa, approving the Technical Regulation that sets operating standards for LTCFs (Brasil, 2005).

Regarding the nursing area, the Ordinance MPAS 73/2001 is the legislation used to quantify the number of professionals that must act on the LTCFs. However, Resolution No. 293/2004 of the Cofen proposes the calculation based on the complexity of the state of health of the patients in hospital facilities, on the operating regime, the weekly workload of professionals of the category and on other indicators (Brasil, 2001; Cofen, 2004; Paula et al., 2014PAULA, R. C. C. et al. Dimensionamento de pessoal de enfermagem em instituições de longa permanência para idosos: proposta de número de horas. Revista Enfermagem Profissional, Rio de Janeiro, v. 1, n. 2, p. 398-412, 2014.). In some entities the nursing staff is far smaller than what is foreseen in legislation, either because LTCFs are covered in Social Assistance, preventing the use of funds to hire professionals of the health area, or due to the nonprofit character of the institutions, which do not have the financial resources to maintain the HR staff.

Resolution No. 15/2012 of the State Secretariat for Social Development (São Paulo, 2012) instituted a multi-sectoral working group composed by members of the Secretariat, NGOs, universities, State Secretariat of Health, instruments of specialized attention to older adults and of LTCFs, with the objective of elaborating standards and standardization for the improvement of the functioning of LTCFs. At least two members also participated in the meetings of the forum, favoring the inclusion of themes and the advances made in the working group.

Expansion and strengthening of the group

The group realized the need to increase the participation of other entities, thus deciding on sending invitations by mail in 2000. Due to the low feedback, the members were divided and made phone contacts. With the advent of the internet, communication improved greatly from the invitations and reminders by e-mail, in addition to personal invitations.

The decrease on the participation of entities was noted and strategies to motivate and resume the presence were proposed. The constant intention of members to keep the rotation of meetings, favoring that each entity shows the services provided and their installations, making them to be known by the group.

Considering the idea of solidarity collaboration proposed by Mance (2001MANCE, E. A. A revolução das redes: a colaboração solidária como uma alternativa pós-capitalista à globalização atual. 2. ed. Petrópolis: Vozes, 2001.), a network capable connecting diversity will be able to fruitfully and creatively integrate the actions taken for the practice of collaboration, articulating its resources and consolidating the implementation of its projects, strengthening each actor to the extent that it maintains a constant flow with the other. The idea of feedback means that actions developed by the network articulate new actions within the network, expanding it and expanding the set of its actions in a virtuous circle capable of engaging more and more actors, corroborating to Alves et. al., (2003) and Cunha and Passador (2007CUNHA, J. A. C.; PASSADOR, J. L. Alianças estratégicas de organizações: o aprendizado institucional na formação de redes. Revista Eletrônica de Ciência Administrativa, Campo Largo, v. 6, n. 1, p. 1-16, 2007.).

Benefits pointed out by the participants

At the end of 2001, the group conducted a self-evaluation process and found that the meetings were fruitful, and there were exchanges of knowledge and willingness to learn new concepts. The participants chose to maintain the discussions of themes related to the institutional daily and/or listed by the group and decided to invest in the expansion of participation of other nonprofit facilities, extending the invitation to the meetings to other bodies. Finally, they considered important to maintain a channel of communication with the Coren through the presence and participation of a representative at the meetings, seeking mechanisms for dialogue.

The reflections, discussions, information and updates were satisfactorily explored, stressing the positive impact on services, allowing changes in the organization of sectors and routines, corroborating to Cunha and Passador (2007CUNHA, J. A. C.; PASSADOR, J. L. Alianças estratégicas de organizações: o aprendizado institucional na formação de redes. Revista Eletrônica de Ciência Administrativa, Campo Largo, v. 6, n. 1, p. 1-16, 2007.). The group agreed to maintain the rotation of the physical space where the meetings were held, because this constituted a personal motivation and professional opportunities, they suggested the continuity of bodily experiences taught by different professionals to introduce new group methodologies, which could be reproduced in the entities.

On the following years there were reports of: exchange of knowledge, information and experiences; tips and techniques to improve customer service; personal and professional growth of the participants and of the group; sharing of doubts and expectations and contact with different professional areas, which provided better knowledge of the possibilities of performance and respect for the work of each one and for differences. Participants assigned to the group the acquirement of support and security, as a space of friendship and partnership. They were able to offer knowledge, experiences, work, availability, dedication and complicity, corroborating Alves et al. (2013ALVES, J. N. et al. Confiança, aprendizagem e conhecimento nos relacionamentos interorganizacionais: diagnóstico e análise dos avanços sobre o tema. Revista Eletrônica de Administração, Porto Alegre, v. 76, n. 3, p. 709-737, 2013.), Fouilleux (2011FOUILLEUX, E. Analisar a mudança: políticas públicas e debates num sistema em diferentes níveis de governança. Estudos Sociedade e Agricultura, Rio de Janeiro, v. 19, n. 1, p. 88-125, 2011.) and Cunha and Passador (2007CUNHA, J. A. C.; PASSADOR, J. L. Alianças estratégicas de organizações: o aprendizado institucional na formação de redes. Revista Eletrônica de Ciência Administrativa, Campo Largo, v. 6, n. 1, p. 1-16, 2007.).

Cramm, Strating and Nieboer (2013CRAMM, J. M.; STRATING, M. M. H.; NIEBOER, A. P. The influence of organizational characteristics on employee solidarity in the long-term care sector. Journal of Advanced Nursing, Hoboken, v. 69, n. 3, p. 526-534, 2013.) report that the formal and informal exchange of knowledge is a form of solidarity among workers of LTCFs, favoring the less hierarchical authority, the decentralization and transforming leadership forms.

They pointed expectations towards the standardization of procedures, technical regulations, formalization of the group, adhesion of new entities and greater knowledge of the other participating institutions; greater interaction and cooperation between the regulatory agencies involved, implementation of ideas proposed and suggested models, continuous learning and harmonization and strengthening of the group.

Prospects and final remarks

The Forum of LTCFs is a successful experience according to the reports recorded in the minutes, especially in its main objective, technical training. The group provides the formation and maintenance of inter-organizational networks with power of expanding and strengthening the relationships between actors, of divulging and disseminating good practices of care and operation and of attracting financial and human resources, such as volunteering.

We note the importance of training in gerontology focusing empowerment and the appropriation of the knowledge of the current legislation and technical standards, as well as of the problems often experienced by residents and by the team of the LTCF. Only after this, the preparation of proposals to the competent bodies and the integration with the scientific and political discussions should be done, to consolidate and legitimize the collective contribution on the construction or revision of public policies for aging.

Among the future prospects are the best use of the potentialities yet to be explored by the forum, such as the organization to purchase and distribute goods, services and HR collectively; the preparation of documents for joint claims, participation in general assemblies and meetings of municipal and state councils for older adults, integrating the forum to the political debates about the need to review existing legislation and the execution of public policies on long-term care; formation of working groups for in-depth discussion of specific themes, among others. We also suggest the periodic re-evaluation of the goals of the group, the collective reset on the formation of the group and the re-registration of participating entities.

The method chosen in this study was the analysis of records of minutes, interviews with the participants were not performed and this is a limitation of the research, which could be restructured with another methodology for comparison between the annotations and the perception/reports of the interviewees. We know that the turnover of members can also make it difficult to obtain a reliable report on the evolution history of the group, suggesting a preference for older and/or regular members and the records of the minutes. Another possibility of research are the reasons for the turnover and absenteeism, elaboration of action plan with strategies to strengthen the group, effective participation of LTCFs and greater proactivity in the meetings.

This study may encourage the development of similar or improved initiatives at other locations, aiming to optimize the benefits of inter-organizational networking between nonprofit institutions that share the same objectives, with the possibility of proposing new research. The establishment of partnerships for technical training and network action can promote the improvement of the provision of long-term care to older adults.

References

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