标题：Transforming together: a pilot project on integrated care in litoral norte health region as part of the project for the strengthening health management in the state of São Paulo
出版社：Utrecht University, Maastricht University, Groningen University
摘要：Introduction : In rethinking the relationship between population health, disease, living conditions, social circumstances and participation, the São Paulo Health State Department (SES/SP) acknowledges the need to reorganize the public healthcare system as a more integrated network in collaboration with the municipalities in view of their critical role in preventive, curative, rehabilitative and health promotion interventions in primary care. SES/SP is taking forward an ambitious project that broadly aligns with the Triple Aim. One element of this ambition is Transforming Together, a pilot transformation project in collaboration with the International Centre for Integrated Care. Short description : This paper describes the concepts, design, scoping and early implementation experience of a transformation programme in primary and community care in the Litoral Norte region. It contrasts implementation experience in Scotland and in Brazil and reflects on shared challenges, common solutions and contextual and cultural differences. Aim and theory of change : The aim is to build capacity for system transformation to an Integrated Care model. The approach adapts breakthrough collaborative methodology to promote adoption of integrated care pathways as an entry point for engaging professionals and managers from different disciplines and levels of care. Together they will design, test and implement changes that create a more integrated health care system within a Regional Health Care Network. Implementing three Care Pathways (for Hypertension and Diabetes; Child Care; and Pregnancy), already developed by SES/SP, will help clarify roles and responsibilities of professionals working at different levels of the Regional Health Care Network and promote a more integrated system response. Targeted population and stakeholders : The target is Litoral Norte (population 300,000, four municipalities with 86% covered by family health units operating from 53 Primary Care centres (UBS)). These serve a geographically defined population and are the gateway, through regulation, to more complex and specialist services. The region has a lower rate of doctors and inpatient beds than the state average with 82% of the beds managed within the public system. Timeline : Initial scoping workshop in March 2017 with clinicians from a number of municipalities generated the concepts for a proposed pilot. High level engagement and knowledge exchange took place 2017 / 2018 with diagnostic and design phase November 2018 – January 2019 to be followed by three action learning cycles February - June. Sustainability and Transferabilty : The pilot will build capacity and confidence in the local teams and coordinating SES/SP staff to enable spread and sustainability of an effective, contextually appropriate transformative appraoch to other regions. System strengthening through the development of primary healthcare and models of integrated care is an increasing priority for many LMI systems. Conclusions : Transformational change is relational and must engage people in a shared purpose. This can be found in rapid testing and implementing of small practical changes through many clinicians learning and improving together with support and coaching by critical friend experts. Transforming Together, a demonstrator for implementing integrated care in Sao Paulo, awill offer considerable learning for other states in Brazil and indeed for other Latin American systems.
关键词：integrated care ; networks ; icp ; primary care ; brazilian public health system
