Impacto das estratégias de integração da atenção no desempenho das redes de serviços de saúde em diferentes sistemas de saúde da América Latina



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Project acronym: Equity-LA II

Grant Agreement Number: 305197

Project title: The impact of alternative care integration strategies on health care networks’ performance in different Latin American health systems

Deliverable: Qualitative results of base-line study

Lead beneficiary: CSC

Nature: Report Dissemination level: Public

Contractual date: 30/06/2015 Actual delivery date: 13/07/2015

Summary

The present deliverable provides the results of the qualitative base-line study that analyses the performance of healthcare networks with respect to coordination and continuity across care levels and its impact in quality of care in different healthcare systems in Latin America. Results are presented by country giving first an introduction including the description of the study areas, the final sample of informants, data collection and analysis; second, the results separated into care coordination and continuity of care for each healthcare network (intervention and control network); and finally the conclusions.



Objective

The objective of the qualitative base-line study was to explore the perception and experiences of healthcare professionals and managers regarding coordination across care levels and the perception and experiences of patients with chronic pathologies including COPD and diabetes mellitus types II regarding continuity across care levels, as well as the factors that influence both coordination and continuity of care, in healthcare networks of different Latin-American countries.

Methods

A descriptive-interpretative, qualitative study was conducted in the study networks (intervention and control) of all the participating Latin-American countries, employing semi-structured interviews and focus groups with a) healthcare professionals, managers, administrative personnel to analyze coordination across levels of care and quality of care and b) patients with chronic conditions (including the tracer conditions) and their carers to analyze continuity of care and its impact on quality of care. Fieldwork took place between March 2014 and February 2015. Data collection finished when saturation of information was achieved. All interviews and focus groups were recorded and transcribed verbatim. A thematic content analysis segmented by country, study area and topic (coordination, continuity) with a mixed generation of categories was carried out, i.e. categories will either derive from the conceptual framework reflected in the topic guides or identified within the data analysis. Quality of data was guaranteed by triangulation of analysists, different types of informant groups and data collection technique.



Results

Colombia

Results on care coordination suggest failures of coordination between primary and specialized care in both healthcare networks. Problems of coordination were identified in a higher proportion by external providers (outside the network). Most relevant were problems regarding coordination of clinical management – lack of agreement among professionals, no follow-up of the patient, restrictions to access specialized care – followed by problems regarding coordination of clinical information and administrative coordination. There was a consensus among actors about the factors that influence health care coordination between the different levels of care: (1) factors related to the healthcare system: the implementation of managed competition and fragmentation benefits package by levels of care showed negative impacts on the response capacity of primary care; (2) factors related to the organization: inadequate working conditions of health professionals and lack of shared coordination mechanisms – an aspect that was most evident in the control network; and (3) factors associated with professionals: low interest of health professionals in the proper use of the mechanisms of coordination of care, distrust of specialists in the work conducted by the general practitioner and deficits in training for health professionals – problems that led to difficulties in teamwork. In relation to mechanisms of coordination, its insufficient implementation was highlighted as a common problem in both networks. Informants highlighted the need for further developing administrative mechanisms, to promote access of patients between different levels of care, as well as mechanisms to coordinate clinical information. To conclude, the results showed a lack of health care coordination between different levels of care in both healthcare networks. The implementation of a model of managed competition promotes fragmented service contracts and competition between service providers, and limits coordination across primary and specialized care.

Regarding continuity of care, patients from both healthcare networks experienced different elements of discontinuity of care. The absence of communication and collaboration between levels of care was identified as a relevant problem in both networks. Concerning continuity of clinical management, patients of both networks highlighted that referrals to specialized care were usually made as a result of a patient’s request and in the presence of complications. Patients further indicated that a low number of referrals were made from specialized care to primary care. Patients of the intervention network recognised that medication errors were usually the result of lack of monitoring in primary care. Barriers to access specialized medicine, mainly due to lack of specialists and constant changes of service providers, led to a follow-up in primary care with poor control of complications. Concerning continuity of information, informants expressed that the absence of formal mechanisms to transfer clinical information led to the shift of responsibilities to the patients to transfer information, and led to the prescription of medicine without enough clinical evidence. Additionally, it was mentioned to be a cause of the inappropriate use of medical appointments, given that test results were not reported on time or got lost. To sum up, users generally reported discontinuity of care in both healthcare networks, regarding continuity of clinical management and continuity of information.

Brazil

Results on coordination of care demonstrate similarities between the intervention and control networks. Regarding the coordination of clinical management, informants reported discontinuity of clinical follow-up, problems in accessibility between levels due to delay in consultations and tests, problems in consistency of care as a result of insufficient sharing of clinical objectives, duplication of tests and treatments and unnecessary referrals and consultations. Concerning coordination of information, a predominance of the use of informal mechanisms (patient and telephone) and insufficient information transfer between levels were identified. The mechanisms for administrative coordination, in some cases, were non-existent. Different factors that influence coordination of care between levels emerged, which are related to (1) the healthcare system: the implementation of public health programs at public universities located in rural areas perceived as a facilitator; the hospital-centred model of care which is still present in the educational system and government actions as a hampering factor; (2) the organization: patient referral centres and communication via Internet and institutional phone were identified as facilitating factors of coordination; limited offer of specialized services and specialists, lack of standardized referral forms and high bureaucracy to access the specialized care were highlighted as distracting factors; (3) the professionals: training of health professionals, available time for care coordination and the primary care physician’s competence as the responsible person for the patient care facilitated coordination; whereas depreciation of primary health care by secondary care professionals and multiple working contracts distracted from coordination.

The preliminary results of continuity of care between care levels suggested that patients perceived that, in most cases, the primary care physicians maintained the prescriptions indicated by the specialists, although the primary care physicians were sometimes unaware of the prescriptions. There were only two interviews that reported duplications of diagnostics tests, perhaps because of difficulties encountered in performing and receiving test results. Patients highlighted that they were aware of the information tools used among physicians of the different health services and almost all patients confirmed that there is no communication between them. To get to know the specialist’s prescribed treatment, the primary care physician asked patients for information, got informed of the medical prescription via the community workers, or used other informal mechanisms. The main difficulty highlighted by users in interviews was the arrangement of specialist’s visits, leading to the need to pay for consultations in private clinics, jeopardizing the family income. In the intervention network, patients also mentioned difficulties to schedule diagnostics tests and receiving the test results. In this network, some specialists are only available when accessing the private system. According to users, different facilitating factors were the good public transport that guaranteed to arrive at the specialist’s office when located in a different city, the physician’s willingness to refer patients to the specialists, the availability of drugs and the support offered by community health workers. Patients mentioned as negative consequences for quality of care the interruptions of treatment because of failing to access the secondary level, the worsening of the disease thus the need to seek emergency care and the difficulty of rehabilitation due to the worsening of the condition. Some diabetics and their relatives reported knowing that the difficult access has even led to the amputation of their diabetic feet.

Chile

In relation to the perception of coordination of care, professionals, managers and administrators from both study networks generally indicate similar difficulties of coordination of the different levels of care and difficulties relating to the coordination of clinical management, with important limitations in access to secondary care, problems of patient follow up as they pass through the network, identifying problems in the consistency of care. The transfer of information is also perceived as problematic in both study networks, especially the information return from the secondary care level to the primary care doctors about the patient referral. Primary care professionals highlight lack of knowledge and communication with professionals of the other levels, which is also confirmed by professionals of this level. Concerning the administrative coordination, on common patterns relating to the difficulties of managing referrals to the various specialties, some differences are identified. Organizational factors of primary and secondary care determine the differences between networks. Different administrative circuits for referrals, as well as the existence of different computer platforms to monitor waiting lists of pathologies that are not covered by the plan for universal access and explicit guarantees (the AUGE health plan) and varying degrees of implementation of the information system for managing electronic medical records in primary care are also identified. Regarding the factors related to the system that affect both networks: the existence of pathologies covered by the AUGE health plan versus those without unequal conditions in the accessibility to specialized care, with elevated waiting times, including the interruption of service processes when being referred. Another system factor relates to the availability and working conditions of specialists; an issue that together with the problems of resources of the managers and professionals is linked to the medical training and the commitment to the public system, competing with the economic interests, that bring them to the private sector.

Regarding the perception of patients of continuity of care, the pattern that emerges without differences between the two study networks - and no major differences by sex/gender or chronic pathology - is the perception of the lack of collaboration of professionals of the different levels of care; as well as serious limitations in accessing adequate care -especially in the secondary and tertiary level- which finally results in the perception that there is a low solution of health problems and increased state of deterioration. Factors of the systems and health services such as the lack of access mainly to specialists and an inappropriate administrative management, together with the own health condition are perceived as the main limitations of continuity of care. The patients perceive that there is no professional responsible for follow up throughout the network, which they consider desirable outside of the doctor's office. In this respect, they feel that they themselves need to manage their health care within the network. In respect to the difficulties of access to the secondary care level, patients highlight strategies such as the use of emergency services and the private system; sometimes the doctors themselves even suggest this way. Most of the users perceived consistency in the diagnosis and treatment among doctors of the different levels, though in some cases disagreements are identified.

Mexico

The results of coordination of care were similar for both networks. Regarding coordination of clinical management, a poor monitoring is found as there were no referrals from specialized to primary care neither did patients go and see the general practitioner. Moreover, inadequate and delayed referrals to the specialist were identified. However, the general practitioner followed the specialist's recommendations and clinical practice guidelines and the Mexican Official Standards were used. Regarding coordination of information, a poor transfer was highlighted because of the bad quality of the registered data, lack of referrals to secondary care and little use of information for clinical decision making. Regarding administrative coordination, a clear picture on referrals from primary to specialized care and vice versa was drawn because of the administrative referral circuits and implemented guidelines. However, in a few cases adherence to guidelines was missing. Particularly in the network of Veracruz, scheduled appointments are used via the Sanitary District. Geographical barriers to access Tarimoya hospital were observed. Meetings for referral across levels are the most recognized mechanisms. Regarding influencing factors, public disinvestment is among the main factors related to the healthcare system affecting coordination of clinical management. Independent work between the centres is an organizational factor influencing the three dimensions of coordination. Little direct communication between physicians in service, but greater between managers, and loss of ethics are the main factors related to professionals, affecting both coordination of clinical management and information. The consequences of lack of coordination for the three dimensions of quality are interruption, delayed or inadequate diagnoses and treatment, potential ineffectiveness that might jeopardize the clinical condition of the patient.



In general, the results of continuity of care are similar for both networks. Regarding continuity of clinical management, respondents identified a limited communication between their attending physicians, disagreements on indicated treatments in both levels and a poor monitoring. With regard to accessibility between levels of care, the respondents point out barriers to access, mainly, the secondary level because of delayed referrals to specialists and need for payment for the services (out-of-pocket). Regarding continuity of information, respondents perceive a general use of the referral form to transfer information from the primary to the secondary level, although they point out little use of the form for referrals from secondary to primary care, using other mechanisms (hospital discharge reports, copies of laboratory analysis, patient’s explanations). Geographical barriers to the Tarimoya Hospital were identified as a trait for the control network. Regarding influencing factors related to the health system, restricted coverage of the Seguro Popular (a program addressing users without social security) and payments for services affected mainly the accessibility between levels of care. Other identified factors – related to services - were deficits in service supply, labour instability of physicians, lack of training and problems in the relationships between physicians from the different levels and between physicians and users. All of this has a negative impact on all kinds and dimensions of continuity. Respondents highlight that their limited financial resources, when feeding into other factors, become an important access barrier.

Argentina

Regarding coordination of care, in both networks, primary care professionals and middle line managers perceive insufficient coordination of clinical management. As for follow-up of patients, informants in both networks recognized that primary care physicians were mainly responsible, although they mention the need for shared responsibility with specialists. Regarding agreements between professionals (coherence of care) of both networks, possible discrepancies in diagnostic criteria and treatments are identified. The specialists perceive specific cases of delayed referrals or cases with possibility of solution at the first level, causing possible clinical complications because of lack of timely intervention. Primary care doctors observe cases of the specialist’s low valuation of primary care, with variations between specialties. Regarding access between levels, primary and secondary care professionals highlight excessive delays in access to appointments with specialists and for complementary studies, which cause multiple consultations at the primary care level and risk of discontinuity of treatments. Professionals of the second level indicate that patients with social security coverage do not access high complex medical tests. Regarding transfer and use of clinical and biopsychosocial information, the absence of a electronic single medical record system is mentioned, which together with the uneven use of referral forms, impede the transfer of information between levels, generating loss of opportunities for clinical intervention. As for administrative coordination, the allocation of appointments presents difficulties related to limited information resources and the congestion of some specialties where the insufficient appointments spaces generate waiting lists. Besides, different time horizons are found in the appointments, with waiting lists being much longer if the appointment making is done at the first level. Among the factors related to the healthcare system that influence care coordination, primary care professionals identify the lack of strengthening of the policy guidelines of the municipality of Rosario, with problems for medium and long term planning. As for organizational factors influencing care coordination, middle line staff highlights that coordination agreements between levels based on interpersonal links rather than on management norms can contribute to the fragmentation of the networks. Primary care professionals identify hierarchical relations between first and second level with disagreements on criteria, and fragmentation of the second level by services and specialties. Professionals of both levels recognize that a high demand does not leave time to be spent on coordination and puts quality of care at risk. Among the factors related to the physicians, physicians of the first level identify different engagement with their work of professionals of both levels; and managers mention the loss of “vocation” for working in public health.

Concerning continuity of care, patients of both networks consider that agreement is found between levels regarding indicated treatments and diagnostic tests. The follow-up of patients in both networks is perceived as a responsibility of primary care, with whom a strong link is registered, although in both networks a strong bond with specialists is also found, depending on their capacity for resolving complex pathologies or frequent episodes of crisis. In both networks, the provision of prescriptions at the first level and results of laboratory tests is mentioned as a mechanism that avoids the duplication of diagnostic tests. Concerning access between levels, identified common elements in both networks are: long waiting times in the allocation of appointments for specialists, tests and surgeries. As for administrative accessibility, in both networks, mechanisms for the allocation of appointments from the first level are identified as well as a system based on a fixed number of appointments for some specialties; shorter, although not optimal, waiting times in programming minor consultations at the primary care level than at the second level. Regarding continuity of information, in both networks users identified: forms for the referrals across levels as a mechanism of communication between professionals; uneven use of referrals from secondary to primary care and the use of the hospital discharge report. Among the factors influencing continuity of care, it was found that in the agreement between primary care doctors and specialists, in both networks, the chronicity of the pathology and the duration of the relationship with the same professionals were important. Among the discrepancies, the insufficient clinical knowledge and the availability of complementary studies to adjust diagnoses are considered. Among the healthcare services, factors that influence administrative accessibility in both networks relate to the existence of pre-established referral circuits, as well as the assignation of specialists per district and the administration of appointments from the first level. As for the continuity of care, scarcity of professionals and lack of replacement during long leaves are factors that have a negative effect on the follow-up of patients. Among the factors that influence continuity of information, both networks identify the turnover of professionals and an uneven knowledge about the patients’ medical records between professionals of both levels. Finally, the severity of the pathology and the explicit demand of a written referral by the physician of the first level are factors that influence the transfer of information from secondary to primary care.



Uruguay

Regarding care coordination, preliminary results of the interviews to professionals showed a similar situation in both networks, revealing a limited coordination between the different levels, closely related to a fragmented organization, and a professional and institutional culture that is focused on the specialised medicine. The results showed a very clear prevalence of a very high fragmented and hierarchical collaboration, where the specialists concentrates the information and offers loyalty to the users, relegating the primary care doctors to a second place. For chronic patients and particularly those with tracer pathologies, the situation is most of the times limited to the repetition of the medication prescribed by the specialist, and the referral of the acute patients to him. Regarding coordination of clinical management, informants revealed under-developed mechanisms, mainly expressed by the low resources available for collaborating (such as, the planed consulting or the clinic supervisions). The administrative coordination is relatively functional, due to being held by skilled professionals only, and coordinated by nursing staff, although technical aspects distract from system efficiency (digitalization and generalization of the electronic management is a still missing goal in the networks). The interviews suggested that the most used means of communication between professionals from different care levels lead to deficiencies of the coordination of the information, which is characterized first by high levels of informal communication (interpersonal phone messages, notes written directly on prescriptions mostly transmitted by the patient him/herself); and second by the under-utilization of tools and communication mechanisms (referral forms, electronic medical history, which is not accessible from both care levels and discharge referral letters).

According to the preliminary results, the interviews to users revealed a convergent perception on continuity of care, which confirms deficient care coordination in both networks. The interviews showed a high level of dependency towards the specialists; against the norms of the care system, the physician of reference was clearly identified and requested by the user to take care of their chronic disease (even through the implementation of strategies to divert the access norms). The first care level was seen as specific support for the renewal of medication and controls between two specialist visits, usually due to the users’ initiative against critical situations, including the episode of the first diagnose of the pathology, which takes place frequently on the first level of attention. The patient is frequently the one to secure the coordination between the two levels, in order to compensate for the deficiencies of information transfer and the administrative management (transfer of clinical history, informal communication between doctors from different levels, request and transfer of test results to avoid duplications).

CONTENTS


Introducción 1

Objetivos 1

Métodos 1

I. Resultados de los estudios cualitativos sobre la coordinación y continuidad de la atención entre niveles en la red de intervención y control en Colombia 3

Introducción 4

a. Descripción de las redes de estudio 4

b. Muestra 4

c. Recogida de la información 8

d. Análisis de datos 8

Resultados 9

1 Estudio de coordinación entre niveles de atención 9

1.1. Red de intervención 9

1.1.1. La coordinación de la atención entre niveles en la red 9

1.1.2. Opinión sobre el rol de los niveles en la atención de los pacientes y su relación con la coordinación entre niveles de atención 22

1.1.3. Conocimiento y utilización de los mecanismos coordinación de la atención entre niveles de atención 24

1.1.4. Estrategias propuestas de mejora de la coordinación y uso de mecanismos de coordinación 34

1.2. Red de control 38

1.2.1. La coordinación de la atención entre niveles en la red 38

1.2.2. Opinión sobre el rol de los niveles en la atención de los pacientes y su relación con la coordinación entre niveles de atención 48

1.2.3. Conocimiento y utilización de los mecanismos de coordinación de la atención entre niveles de atención 49

1.2.4. Estrategias propuestas de mejora de la coordinación y uso de los mecanismos de coordinación 62

2 Estudio de continuidad entre niveles de atención 67

2.1 Red de intervención 67

2.1.1 Percepción de la continuidad de la atención entre niveles en la red 67

2.1.2 Factores que facilitan o dificultan la continuidad de atención entre niveles 82

2.1.3 Estrategias propuestas de mejora de la continuidad entre niveles de atención 84

2.2 Red de control 87

2.2.1 Percepción de la continuidad de la atención entre niveles en la red 87

2.2.2 Factores que facilitan o dificultan la continuidad de atención entre niveles 103

2.2.3 Estrategias propuestas de mejora de la continuidad entre niveles de atención 106

Conclusiones 110

II. Resultados do estudos qualitativos sobre a coordenaçao ea continuidade da atenção entre niveis na rede de intervenção e controle no Brasil 113

Introdução 114

1. Descrição das redes de estudo 114

2. Amostra 116

3. Coleta dos dados 120

4. Análise dos dados 122

Resultados 123

1. Estudo de coordenação entre os níveis de atenção 123

1.1 Rede de Intervenção 123

1.1.1 A coordenaçao da atençao entre os niveis na rede 123

1.1.2 Opinião sobre o papel dos níveis na atenção dos pacientes e sua relação com a coordenação entre níveis de atenção 135

1.1.3 Conhecimento e utilização de mecanismos de coordenação do cuidado entre os níveis de atenção 143

1.1.4 Estratégias propostas para melhorar a coordenação e utilização dos mecanismos de coordenação 154

1.2 Rede de Controle 157

1.2.1 A coordenação da atenção entre níveis na rede 157

1.2.2 Opinião sobre o papel dos níveis na atenção aos pacientes e sua relação com a coordenação entre níveis de atenção 165

1.2.3 Conhecimento e utilização dos mecanismos de coordenação da atenção entre os níveis de atenção 169

1.2.4 Estratégias propostas para melhorar a coordenação e o uso dos mecanismos de coordenação 179

2. Estudo de continuidade entre os níveis de atenção (resultados preliminares) 182

2.1 Redes de intervençao 182

2.1.1 Percepção da continuidade da atenção entre níveis na rede 182

2.1.2 Fatores que facilitam ou dificultam a continuidade de atenção entre níveis 192

2.1.3 Estratégias propostas de melhoria da continuidadeentre níveis de atenção 195

2.2 Rede de controle 197

2.2.1 Percepção da continuidade da atenção entre níveis na rede 197

2.2.2 Fatores que facilitam ou dificultam a continuidade da atenção entre níveis 208

Conclusões 211

III. Resultados de los estudios cualitativos sobre la coordinación y continuidad de la atención entre niveles en la red de intervención y control en Chile 213

Introducción 214

1. Descripción de las redes de estudio 214

2. Muestra 214

3. Recogida de la información 217

4. Análisis de datos 218

Resultados 220

1 Estudio de coordinación entre niveles de atención 220

1.1. Red de intervención 220

1.1.1. La coordinación de la atención entre niveles en la red 220

1.1.2. Opinión sobre el rol de los niveles en la atención de los pacientes y su relación con la coordinación entre niveles de atención 247

1.1.3. Conocimiento y utilización de los mecanismos de coordinación de la atención entre niveles de atención 249

1.2. Red de control 256

1.2.1. La coordinación de la atención entre niveles en la red 256

2 Estudio de continuidad entre niveles de atención 262

2.1. Red de intevención 262

2.1.1. Percepción de la continuidad de la atención entre niveles en la red 262

2.1.2. Factores que facilitan o dificultan la continuidad de atención entre niveles 272

2.1.3. Estrategias propuestas de mejora de la continuidad entre niveles de atención 277

2.2. Red de control 280

2.2.1. Percepción de la continuidad de la atención entre niveles en la red 280

2.2.2. Factores que facilitan o dificultan la continuidad de atención entre niveles 290

2.2.3. Estrategias propuestas de mejora de la continuidad entre niveles de atención 293

Conclusiones 296

IV. Resultados de los estudios cualitativos sobre la coordinación y continuidad de la atención entre niveles en la red de intervención y control en México 299

Introducción 300

1. Descripción de las redes de estudio 300

2. Muestra 300

3. Recogida de la información 304

4. Análisis de datos 304

Resultados 306

1 Estudio de coordinación entre niveles de atención 306

1.1. Red de intervención 306

1.1.1. La coordinación de la atención entre niveles en la red 306

1.1.2. Opinión sobre el rol de los niveles en la atención de los pacientes y su relación con la coordinación entre niveles de atención 328

1.1.3. Conocimiento y utilización de los mecanismos de coordinación de la atención entre niveles de atención 330

1.1.4. Estrategias propuestas de mejora de la coordinación y uso de los mecanismos de coordinación 343

1.2. Red de Control 349

1.2.1. La coordinación de la atención entre niveles en la red 349

1.2.2. Opinión sobre el rol de los niveles en la atención de los pacientes y su relación con la coordinación entre niveles de atención 366

1.2.3. Conocimiento y utilización de los mecanismos de coordinación de la atención entre niveles de atención 367

1.2.4. Estrategias propuestas de mejora de la coordinación y uso de los mecanismos de coordinación 379

2. Estudio de continuidad entre niveles de atención 385

2.1. Red de intervención 385

2.1.1. Percepción de la continuidad de la atención entre niveles en la red 385

2.1.2. Factores que facilitan o dificultan la continuidad de atención entre niveles 398

2.1.3. Estrategias propuestas de mejora de la continuidad entre niveles de atención 403

2.2. Red de control 406

2.2.1. Percepción de la continuidad de la atención entre niveles en la red 406

2.2.2. Factores que facilitan o dificultan la continuidad de atención entre niveles 418

2.2.3. Estrategias propuestas de mejora de la continuidad entre niveles de atención 424

Conclusiones 426

V. Resultados de los estudios cualitativos sobre la coordinación y continuidad de la atención entre niveles en la red de intervención y control en Argentina 432

Introducción 433

1. Descripción de las redes de estudio 433

2. Muestra 438

3. Recogida de la información 441

4. Análisis de datos 441

Resultados 442

1. Estudio de coordinación de la atención entre niveles en la red 442

1.1. Red de intervención 442

1.1.1. La coordinación de la atención entre niveles en la red 442

1.1.2. Opinión sobre el rol de los niveles en la atención de los pacientes y su relación con la coordinación entre niveles de atención 483

1.1.3. Conocimiento y utilización de los mecanismos de coordinación de la atención entre niveles de atención 485

1.1.4. Estrategias propuestas de mejora de la coordinación y uso de los mecanismos de coordinación 489

1.2. Red de control 492

1.2.1. La coordinación de la atención entre niveles en la red 492

1.2.2. Opinión sobre el rol de los niveles en la atención de los pacientes y su relación con la coordinación entre niveles de atención 523

1.2.3. Conocimiento y utilización de los mecanismos de coordinación de la atención entre niveles de atención 526

1.2.4. Estrategias propuestas de mejora de la coordinación y uso de los mecanismos de coordinación 533

2. Estudio de continuidad entre niveles de atención 537

2.1. Red de intervención 537

2.1.1. Percepción de la continuidad de la atención entre niveles en la red 537

2.1.2. Factores que facilitan o dificultan la continuidad de atención entre niveles 556

2.1.3. Estrategias de propuestas de mejora de la continuidad entre niveles de atención 556

2.2. Red de control 558

2.2.1. Percepción de la continuidad de la atención entre niveles en la red 558

2.2.2. Factores que facilitan o dificultan la continuidad de atención entre niveles 575

2.2.3. Estrategias propuestas de mejora de la continuidad entre niveles de atención 575

Conclusiones 577

VI. Resultados de los estudios cualitativos sobre la coordinación y continuidad de la atención entre niveles en la red de intervención y control en Uruguay 583

Introducción 584

1. Descripción de las redes de estudio 584

2. Muestra 592

3. Recogida de la información 594

4. Análisis de datos 595

Resultados preliminares 596

1. Estudio de coordinación entre niveles de atención 596

1.1 Red de intervención 596

1.1.1. La coordinación de la atención entre niveles en la red 596

1.1.2. Opinión sobre el rol de los niveles en la atención de los pacientes y su relación con la coordinación entre niveles de atención 608

1.1.3. Conocimiento y utilización de los mecanismos de coordinación entre niveles de atención 610

1.1.4. Estrategias propuestas de mejora de la coordinación y uso de los mecanismos de coordinación 611

1.2 Red de control 613

1.2.1 La coordinación de la atención entre niveles en la red 613

1.2.2 Opinión sobre el rol de los niveles en la atención de los pacientes y su relación con la coordinación entre niveles. 618

1.2.3 Conocimiento y utilización de los mecanismos de coordinación de la atención entre niveles de atención 619

1.2.4 Estrategias propuestas de mejora de la coordinación y uso de los mecanismos de coordinación 619

2. Estudio de coordinación entre niveles de atención 621

2.1. Red de intervención 621

2.1.1. Percepción de la continuidad de la atención entre niveles en la red 621

2.1.2. Factores que facilitan o dificultan la continuidad de atención entre niveles 626

2.1.3. Estrategias propuestas de mejora de la continuidad entre niveles de atención 627

2.2. Red de control 629

2.2.1. Percepción de la continuidad de la atención entre niveles en la red 629

2.2.2. Factores que facilitan o dificultan la continuidad de atención entre niveles 631

2.2.3. Estrategias propuestas de mejora de la continuidad entre niveles de atención 633

Conclusiones 635







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