EADES - Equipe de Apoio à Desospitalização e Educação em Saúde
Hospital federal de Bonsucesso

A. Problem Analysis

 1. What was the problem before the implementation of the initiative?
The Federal Hospital of Bonsucesso is a public hospital of quaternary level specialized in surgeries of high complexity and also with an Unit of Attention of High Complexity in Oncology (UNACON). Located on Avenida Brasil is the first option of emergency medical care with opend doors for hundreds of thousands of residents of the Metropolitan Region of Rio de Janeiro, a region lacking public health services. Due to its assistance profile, its Emergency Support Unit was constantly overcrowded beyond its capacity to service. The profile of the patients who were able to receive care was varied, however more than 50% were patients with oncologic disease in palliative care. These patients were hospitalized in the emergency room for up to more than 20 days, preventing bed rotation and care for other patients with possible treatment and cure. One of the most common causes of long-term care was the lack of support network in the hometowns of patients able to meet their demands for care beyond the fear of their families. It was necessary to create a service that would work to responsibility discharge these patients to their relatives, caregivers and health staff outside the hospital. So that they could be discharged responsibly with easy access to public health services closer to their home residence and the continuity of home care level garanteed. The Support Team for Dehospitalization and Health Education was created in August 2011.

B. Strategic Approach

 2. What was the solution?
The Support Team for De-hospitalization and Health Education works by supporting all subjects (patients, relatives, caregivers, health professionals, managers) involved in the management of the de-hospitalization processes through the organization of health care networks (housemades, relatives, Health services, intersectoral) and health education actions (educational campaigns, lectures, courses, preceptory, behavioral change, reengineering of processes, etc.) carried out by the team.

 3. How did the initiative solve the problem and improve people’s lives?
Carrying out active search of patients with cancer on palliative care in the hospital emergency unit every Monday, the Support Team for De-hospitalization and Health Education was able to identify early those who presented greater social, economic-financial and structural-family vulnerability. Working together with the relatives / social groups and caregivers of these patients since the beginning of the hospitalization process, the Support Team for De-hospitalization and Health Education created strong trusted links that facilitated the access to information about their diagnostic and therapeutic itineraries since the beginning of the appearance of the first symptoms until the moment of the hospital admission. This information allowed the problems and failures of health care networks to be identified and collectively addressed or mitigated. If the origin of these problems was within family / home relations, the Support Team for De-hospitalization and Health Education invited the family and social groups to a meeting where all doubts related to the Right to Health, Health Systems and Health Cares were clarified. As well as the necessary directions were made so that most of the problems identified could be solved, whether they be family, structural or financial. Families and social groups that would take care of their patients in their homes were referred to care professionals at emergency unit (nurses, physiotherapists, speech therapists, nutritionists etc.) to learn from an early time how direct body care should be performed. Family members and social groups were advised on the division of labor at home and away from home so that none would be overwhelmed with the demands of their patients. The households where the patients would live after hospital discharge were modified / adapted to better receive them. Labor and pension issues of the patients were organized so that their rights were guaranteed, especially those that could generate some extra financial income for the patients. If the origin of these problems was within the public health services network, the Support Team for Dehospitalization and Health Education activated the teams of health professionals external to the Federal Hospital of Bonsucesso and the transfers of patients from the hospital to the specific networks were made from structured, responsible and interpersonal. In carrying out all these actions since the beginning of the patients' hospitalization process, the Support Team for Dehospitalization and Health Education was able to combine the moment when the patients obtained clinical improvement and were discharged with all the necessary organization to guarantee a Hospital discharge.

C. Execution and Implementation

 4. In which ways is the initiative creative and innovative?
Untill today, the Brazilian Health System (SUS) has not developed and implemented a de-hospitalization policy for patients with long-term illness hospitalized in general hospitals. Nor academic studies are dealing specifically with this subject. Without funding and with only three professionals, the Support Team for De-hospitalization and Health Education was seeking experiences in the writings of psychiatric reform to build their work proposal. It was noted that this movement had its greater focus of investment in cultural transformation only for health professionals and technicians, and not in the families and social groups of the mentally illness, and this has led to many delays and misunderstandings in the processes of deinstitutionalization of these subjects. The Support Team for Dehospitalization and Health Education included the family in the processes of management of the patients' care since the beginning of the process of hospitalization in the hospital. In addition, the Support Team for Dehospitalization and Health Education extends its health education actions to the future health professionals in training.

 5. Who implemented the initiative and what is the size of the population affected by this initiative?
The Support Team for Dehospitalization and Health Education is a multiprofessional team whose management is carried horizontally and collectively out by its own members. She is currently formed by professionals from the following categories: Nursing, Psychology and Social Assistence. In addition, the Support Team of De-hospitalization and Health Education is an internship field for students of Nursing, Social Assistence and Public Health (whose initial training covers the most varied graduations). Within the organization chart of the Federal Hospital of Bonsucesso it is integrated to the Internal Nucleus of Regulation that is part of the Medical-Assistance Division. The Federal Hospital of Bonsucesso is a public health unit financed by the Ministry of Health of Brazil. It is located in the city of Rio de Janeiro and is part of a broad network containing 5 more general hospitals and 3 institutes. This network is planning the creation of a Technical Board for De-hospitalization whose main goals are the replication of the work methods of the Support Team for Dehospitalization and Health Education as well as the creation of a De-hospitalization Policy to be proposed for the entire Brazilian Health System (SUS).
 6. How was the strategy implemented and what resources were mobilized?
Before the Support Team for Dehospitalization and Health Education was set up, its professionals worked to provide care at the household level to the patients who had discharged from the Federal Hospital of Bonsucesso. In August 2011, the Ministry of Health published an ordinance that reorganized the network of Home Care Services throughout the country. Part of this reorganization affected directly the function of these services. They ceased to be a hospital service to become a primary care service. As a result, their funding has also changed and hospitals are no longer counting on specific budget resources for this type of health care delivery. The team of professionals of the Home Care Service of the Federal Hospital of Bonsucesso together with the managers of that time was obliged to formed and redesigned their action project according to the most urgent needs of the institution that was the lack of rotation of the emergency beds occupied with patients with cancer on palliative care. Initially, the Support Team for Dehospitalization and Health Education only worked identifying the health care networks of professionals outside the hospital to refer their patients. Over time, the activities were being improved and other tipes of patients were included in the list of patients cared as the elderly and those with long-term non-oncological diseases. Today the Support Team for De-hospitalization and Health Education has developed the De-hospitalization Program its composed of 3 macro-processes that are subdivided on sub-processes. The first macro-process "CAPTAÇÃO (Gatter)" is the first to be carried out by the Support Team for De-hospitalization and Health Education and its main goal is the Family Meeting, which consists, in brief, includes the family in the management of health cares of their relatives. This stage is essential for the beginning of the other 2 macro-processes, during which the patients' home address after hospital discharge and who will be the family caregivers are defined. The second macro-process "REDES DE ATENÇÃO À SAÚDE (Networks of Attention to Health)" consists in surveying the demands of continuous care of the patients and in the organization of health care networks of professionals adapted to the needs of each patient. The third macro-process "CUIDADOS (Care)" organizes the training steps of family caregivers during the hospitalization process of the patients being followed up. All patients accompanied by the Support Team for Dehospitalization and Health Education remain under their supervision until they leave the hospital, and even after their arrival at home, the Support Team of De-hospitalization and Health Education continues to monitor them through telephone calls to your home, your caregivers, and your referrals. As mentioned earlier, the extraordinary funding that was earmarked for the Home Care Service was suspended, and the Federal Hospital of Bonsucesso was responsible for maintaining the service of the Support Team for Dehospitalization and Health Education only with its own budget. The Support Team for Dehospitalization and Health Education uses 3 rooms within the entire physical structure of the hospital whose cost of maintenance (cleaning, telephony, internet, electricity, etc.) is prorated with all other facilities of the complex of six buildings. The members of the Support Team for De-hospitalization and Health Education are all federal servants whose salaries are not deducted from the hospital budget.

 7. Who were the stakeholders involved in the design of the initiative and in its implementation?
During the design of the initiative, the Support Team for Dehospitalization and Health Education counted on the advice of the General Directorate of the hospital and the members of the Internal Regulation Nucleus. Many considerations from the Federal Hospital de Bonsucesso care professionals, family members and communicators, and caregivers of the patients being followed were discussed by the Support Team for Dehospitalization and Health Education During their monthly service evaluation meetings. The professionals who work with dehospitalization in the federal network of hospitals and institutes of the city of Rio de Janeiro hold monthly forums to discuss problems encountered during the execution of this process and the survey of possible solutions to be implemented that are also taken into consideration by the Team Support for De-hospitalization and Health Education in the search for greater effectiveness and better quality of its de-hospitalization program.

 8. What were the most successful outputs and why was the initiative effective?
We can consider that the Support Team for Dehospitalization and Health Education and its De-hospitalization Program are a successful initiative because: 1. Intervened in the behavior of care professionals of the Federal Hospital of Bonsucesso who previously did not think about the continuity of care and care at the household level since the beginning of the hospitalization process of the patients, leaving to prepare the family and establish the network of attention to the external health to the hospital only at the moment the attending physician signed the clinical discharge; 2. Changed a culture in the Nursing work routine that previously prohibited the presence of family members and patients' companions accompanied by the Support Team for Dehospitalization and Health Education at all the time of performing hygiene, dressings and other direct care to the body, and that today can already be negotiated; 3. He was the object of a master's degree research in the graduate program in Collective Health of the Institute of Social Medicine of the State University of Rio de Janeiro; 4. Trained the Multiprofessional Home Care Team of the Fernandes Figueira Institute of FIOCRUZ to perform de-hospitalization according to its De-hospitalization Program; 5. Became an internship field for the Multiprofessional Residency in Collective Health of the Institute of Studies in Collective Health of the Federal University of Rio de Janeiro and for the Residency in Medical-Surgical Nursing of the Federal University of the City of Rio de Janeiro. The Support Team for Dehospitalization and Health Education uses a light technology - the conversation - in the execution of their work. It is through this dialogical practice that information and knowledge about the functioning of the Brazilian Health System (SUS) and the laws that guarantee health rights are disseminated to all users of the system. With this acquired knowledge citizens become more autonomous and politically empowered. This allows them to fight for their rights, which when exercised contribute to the reduction of existing social inequality, to the improvement of their health conditions and their well-being and to their professional training.

 9. What were the main obstacles encountered and how were they overcome?
It is never easy to implement an initiative that has in its scope a proposal for cultural change and with the Support Team for Dehospitalization and Health Education it was no different. The first obstacle was the cut of the financing line that paid for the then Home Care Service; without that money we lose cars, drivers and other inputs. This obstacle has not been overcome and until today we have suffered from the cut of the health budget by the federal government that makes it impossible for us to increase the Support Team for Dehospitalization and Health Education with more professionals from other categories, a more modern technological park and necessary production inputs for the production of educational campaigns and thematic seminars. The second obstacle is found in people, old professionals fearful of change that create resistance to initiatives proposed by the Support Team for De-hospitalization and Health Education and former service heads who see the emergence of a new group within the old institution as a threat to their established power. This obstacle was partly overcome through many meetings and many conversations, but we still find professionals reactive to our proposals of work. The third obstacle is the lack of political definition, since the emergence of the Support Team for Dehospitalization and Health Education in 2011 we had three changes of the president, health ministers and hospital directors. This obliges us to constantly restart the negotiations that were already under way and try to regain what has already been done; an eternal start from scratch.

D. Impact and Sustainability

 10. What were the key benefits resulting from this initiative?
Dehospitalization Program of the Support Team for De-hospitalization and Health Education of the Federal Hospital of Bonsucesso seeks to guarantee. By bringing the families and social groups of the patients accompanied by the Support Team for Dehospitalization and Health Education to participate in the care management processes from the first moments of their hospitalization, we significantly observed the decrease of cases in that the family refused in to agree on the execution of certain traumatic and invasive procedures, reducing the length of stay and the complications inherent to hospital admission procedures. When we organize the health care networks specifically to the demands of continued care of each patient accompanied by the Support Team for Dehospitalization and Health Education and when we perform the early and interpersonal referral of each family to enroll and register in the identified services, we observe that access to public health services, the basic principle of the SUS was facilitated and had their effectiveness guaranteed. This has reduced the insecurity of families, caregivers and patients themselves returning home at the time of hospital discharge as well as the number of hospital readmissions for reasons treatable in the primary and secondary health care network. When we carry out health education actions inside and outside the hospital with patients, family members, caregivers, managers, professionals and future health professionals, we realize that issues related to the way the health system works, its regiments and legal systems and how we can demand and exercise our legally guaranteed health rights were absorbed by the served population and transformed them into more conscious and politically active citizens, improving the social control of SUS. These changes were measured through the monitoring calls to the residences of the patients, to the services that the patients were referred to, besides to the speeches and practices of professionals and future professionals during their practice in the fields of practice.

 11. Did the initiative improve integrity and/or accountability in public service? (If applicable)

 12. Were special measures put in place to ensure that the initiative benefits women and girls and improves the situation of the poorest and most vulnerable? (If applicable)

Contact Information

Institution Name:   Hospital federal de Bonsucesso
Institution Type:   Ministry  
Contact Person:   LUCIANO Rocha
Title:   Coordinator  
Telephone/ Fax:   +552139779619
Institution's / Project's Website:  
E-mail:   rocha.luciano@gmail.com  
Address:   Rua Camarista Meier 721, Engenho de Dentro
Postal Code:   20730-234
City:   RIO DE JANEIRO
State/Province:   Rio de Janeiro
Country:  

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