[Barriers and factors associated with the use of coordination mechanisms between levels of care in Mexico]

Decentralizing referral prioritization to general practitioners at the primary care level: A qualitative case study based on the Grounded Theory

BACKGROUND

Patient referral prioritizations is an essential process in coordinating healthcare delivery, since it organizes the waiting lists according to priorities and availability of resources.

OBJECTIVE

This study aims to highlight the consequences of decentralizing ambulatory patient referrals to general practitioners that work as family physicians in primary care clinics.

METHODS

A qualitative case study was carried out in the municipality of Rio de Janeiro. The ten health regions of Rio de Janeiro were visited during fieldwork, totalizing 35 hours of semi-structured interviews and approximately 70 hours of analysis based on the Grounded Theory.

RESULTS

The findings of this study show that the obstacles to adequate referrals are beyond the management of vacancies, ranging from the standardization of prioritization criteria to ensuring the proper employment of referral protocols in diverse locations assisted by overloaded health workers with different backgrounds and perceptions. Efforts in decentralizing patient referral to primary care still face the growing dilemmas and challenges of expanding the coverage of health services while putting pressure on risk assessment, as well as sustaining the autonomy of physicians' work while respecting the eligibility when ordering waiting lists.

CONCLUSION

A major strength of this work is on the method to organize and aggregate qualitative data using visual representations. Limitations concerning the reach of fieldwork in vulnerable and hardly accessible areas were overcame using snowball sampling techniques, making more participants accessible.

Lessons learnt from the process of designing care coordination interventions through participatory action research in public healthcare networks of six Latin American countries

BACKGROUND

The participation of health professionals in designing interventions is considered vital to effective implementation, yet in areas such as clinical coordination is rarely promoted and evaluated. This study, part of Equity-LA II, aims to analyse the design process of interventions to improve clinical coordination, taking a participatory-action-research (PAR) approach, in healthcare networks of Argentina, Brazil, Chile, Colombia, Mexico and Uruguay. This participatory process was planned in four phases, led by a local steering committee (LSC): (1) dissemination of problem analysis results and creation of professionals' platform, (2) selection of problems and intervention (3) intervention design and planning (4) adjustments after evaluation of first implementation stage.

METHODS

A descriptive qualitative study based on documentary analysis, using a topic guide, was conducted in each intervention network. Documents produced regarding the intervention design process were selected. Thematic content analysis was conducted, generating mixed categories taken from the topic guide and identified from data. Main categories were LSC characteristics, type of design process (phases, participants' roles, methods) and associated difficulties, coordination problems and interventions selected.

RESULTS

LSCs of similar composition (managers, professionals and researchers) were established, with increasing membership in Chile and high turnover in Argentina, Colombia and Mexico. Following results dissemination and selection of problems and interventions (more participatory in Chile and Colombia: 200-479 participants), the interventions were designed and planned, resulting in three different types of processes: (1) short initial design with adjustments after first implementation stage, in Colombia, Brazil and Mexico; (2) longer, more participatory process, with multiple cycles of action/reflection and pilot tests, in Chile; (3) open-ended design for ongoing adaptation, in Argentina and Uruguay. Professionals' time and the political cycle were the main barriers to participation. The clinical coordination problem selected was limited communication between primary and secondary care doctors. To address it, through discussions guided by context and feasibility criteria, interventions based on mutual feedback were selected.

CONCLUSIONS

As expected in a flexible PAR process, its rollout differed across countries in participation and PAR cycles. Results show that PAR can help to design interventions adapted to context and offers lessons that can be applied in other contexts.

Interventions to Improve Clinical Coordination between Levels: Participatory Experience in a Public Healthcare Network in Xalapa, Mexico

INTRODUCTION

Coordination of care can be improved through an intervention or a combination of several ones. In addition, it is recommended to encourage the active involvement of professionals in the design, implementation and assessment of coordination mechanisms.

OBJECTIVE

To analyse the factors that influence the implementation of participatively designed interventions and their effects on clinical coordination between levels of care in a public healthcare network of health services in Xalapa, Veracruz, Mexico.

METHODS

A qualitative, descriptive-interpretative study, for which individual interviews and discussion groups with a criterion sample of participants: Local Steering Committee and the Professional Platform. A content analysis, with mixed category generation and segmentation by intervention and topics, was carried out. According to the problem analysis, participants designed two sequential interventions: offline virtual consultation, and joint training meetings on maternal health and chronic diseases.

RESULTS

Respondents perceived a differentiated impact on clinical coordination according to intervention: greater in the case of joint maternal health trainings and limited for the chronic diseases meetings, as they were the offline virtual consultation was rarely used.

CONCLUSION

The involvement of professionals in designing the interventions, as well as institutional support and reflexive methods for training, all decisively improved clinical coordination between levels.