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Although fragmentation in the provision of services is considered an obstacle to effective health care, there is scant evidence on the impact of interventions to improve care coordination between primary care and secondary care in terms of continuity of care—i.e. from the patient perspective—particularly in Latin America (LA). Within the framework of the Equity-LA II project, interventions to improve coordination across care levels were implemented in five Latin American countries (Brazil, Chile, Colombia, Mexico and Uruguay) through a participatory action research (PAR) process. This paper analyses the impact of these PAR interventions on the cross-level continuity of care of chronic patients in public healthcare networks. A quasi-experimental study was performed with measurements based on two surveys of a sample of patients with chronic conditions (392 per network; 800 per country). Both the baseline (2015) and evaluation (2017) surveys were conducted using the CCAENA questionnaire. In each country, two comparable public healthcare networks were selected, one intervention and one control. Outcomes were cross-level continuity of information and clinical management continuity. Descriptive analyses were conducted, and Poisson regression models with robust variance were fitted to estimate changes. With differences between countries, the results showed improvements in cross-level continuity of clinical information (transfer of clinical information) and clinical management continuity (care coherence). These results are consistent with those of previous studies on the effectiveness of the interventions implemented in each country in improving care coordination in Brazil, Chile and Colombia. Differences between countries are probably related to particular contextual factors and events that occurred during the implementation process. This supports the notion that certain context and process factors are needed to improve continuity of care. The results provide evidence that, although the interventions were designed to enhance care coordination and aimed at health professionals, patients report improvements in continuity of care.

Healthcare coordination is considered key to improving care quality. Although participatory action research (PAR) has been used effectively to bridge the gap between evidence and practice in other areas, little is known about the key success factors of its use in healthcare organizations. This article analyses the factors influencing the implementation of PAR interventions to improve clinical coordination from the perspective of actors in public healthcare networks of Brazil, Chile, Colombia, Mexico and Uruguay. A qualitative, descriptive-interpretative study was conducted in each country’s healthcare network. Focus groups and semi-structured individual interviews were conducted to a criterion sample of: local steering committee (LSC) (29), professional platform (PP) (28), health professionals (49) and managers (28). Thematic content analysis was conducted, segmented by country and themes. The PAR process led by the LSC covered the return of baseline results, selection of problems and interventions and design, implementation and adjustment of the intervention, with PP. Interventions were implemented to improve communication and clinical agreement between primary and secondary care. Results reveal that contextual factors, the PAR process and the intervention’s content influenced their implementation, interacting across time. First, institutional support providing necessary resources, and professionals’ and managers’ willingness to participate, emerge as contextual pivotal factors, influenced by other factors related to: the system (alignment with policy and political cycle), networks (lack of time due to work overload and inadequate working conditions) and individuals (not knowing each other and mutual mistrust). Second, different characteristics of the PAR process have a bearing, in turn, on institutional support and professionals’ motivation: participation, flexibility, consensual decision-making, the LSC’s leadership and the facilitating role of researchers. Evidence is provided that implementation through an adequate PAR process can become a factor of motivation and cohesion that is crucial to the adoption of care coordination interventions, leading to better results when certain contextual factors converge.

Despite relational continuity (RC) with the doctor being key to care quality for chronic patients, particularly in fragmented healthcare systems, like many in Latin America (LA), little is known about RC and its attributes, particularly regarding specialists. Aim: We aim to analyse chronic patients’ perceptions of RC with primary (PC) and secondary (SC) care doctors, and record changes between 2015 and 2017 in the public healthcare networks of six LA countries. An analysis of two cross-sectional studies applying the CCAENA questionnaire to chronic patients (N = 4881) was conducted in Argentina, Brazil, Chile, Colombia, Mexico, and Uruguay. The dependent variables of RC with PC and SC doctors were: consistency, trust, effective communication, and synthetic indexes based on RC attributes. Descriptive and multivariate analyses were performed. Although the RC index was high in 2015, especially in PC in all countries, and at both levels in Argentina and Uruguay, low perceived consistency of PC and SC doctors in Colombia and Chile and of SC doctors in Mexico revealed important areas for improvement. In 2017 the RC index of SC doctors increased in Chile and Mexico, while SC doctors’ consistency in Colombia decreased. This study reveals important gaps in achieving RC with doctors, particularly in SC, which requires further structural and organisational reforms.

Background Finding new strategies for care integration has become a policy priority for many fragmented health systems in Latin America. Although the implementation of interventions through a participatory action research (PAR) approach is considered to be more effective in achieving organizational change, its application is scarce. This study, part of the research project Equity-LA II, aims to analyze the impact of PAR interventions on care coordination across levels, and key aspects for their sustainability and transferability, from the stakeholder viewpoint in healthcare networks of Brazil, Chile, Colombia, Mexico and Uruguay. Different interventions were designed and implemented through a PAR process to improve communication and clinical agreement between primary care and secondary care doctors: joint meetings to discuss clinical cases and/or training; shared care guidelines; offline virtual consultations; a referral and reply letter; and an induction program. Methods A qualitative, descriptive-interpretative study was conducted in the healthcare network of each country. Focus groups and semi-structured individual interviews were conducted with a criterion sample of participants: local steering committee (29) and professional platform members (28), other health professionals (49) and managers (28). Thematic content analysis was conducted, segmented by country and type of intervention. Results Informants highlighted that joint meetings based on reflexive methods contributed substantially to improving contextually relevant elements of clinical management coordination – communication in patient follow-up, clinical agreement, appropriateness of referrals – and also administrative coordination. The meetings, alongside the PAR process, also helped to improve interaction between professionals – knowing each other personally and mutual trust – thus fostering willingness to collaborate. The PAR approach, moreover, served to spread awareness of the coordination problems and need for intervention, encouraging greater commitment and interest in participating. No noteworthy contributions were identified in remaining interventions due to low uptake. A necessary condition for the sustainability and replicability was that PAR process had to be used appropriately in a favourable context. Conclusions Evidence is provided on the substantial contribution of interventions to improving locally relevant clinical coordination elements and professional interaction when implemented through an adequate PAR process (in terms of time, method and participation levels), a necessary condition for their sustainability and replicability.

Background Finding new strategies for care integration has become a priority for many health systems in Latin America. Although the implementation of interventions through a participatory action research (PAR) approach is considered effective, its application in health services is scarce. Aim to analyse impact of PAR interventions on care coordination, and aspects for sustainability and transferability in public healthcare networks of Brazil, Chile, Colombia, Mexico and Uruguay. Methods A qualitative, descriptive-interpretative study was conducted in each healthcare network. Focus groups and individual semi-structured interviews were conducted to a criteria sample of Local Steering Committee (29), Platform of professionals (28), professionals (49) y managers (28). A thematic content analysis was conducted, segmented by country and themes. Different interventions were designed and implemented through a PAR process: joint meetings to discuss clinical cases and/or training; shared care guidelines; offline virtual consultations; a (back) referral form; and an induction program. Results Informants highlighted that joint meetings based on reflexive methods contributed substantially to improving contextually relevant elements of clinical coordination - communication in patient follow-up, clinical agreement, appropriateness of referrals - and administrative coordination. The meetings, alongside the PAR process, helped to improve interaction between professionals, fostering willingness to collaborate. No significant contributions were identified in the remaining interventions due to the low uptake. A necessary condition for the sustainability and replicability of the interventions was that the PAR process had to be used appropriately in a favorable context. Conclusions Evidence is provided on the significant contribution of interventions to improving locally relevant clinical coordination elements and professional interaction when implemented through an adequate PAR process. Key messages It contributes to fill the gap regarding the impact of PAR interventions on care coordination. A key aspect for impact and sustainability is an adequate use of PAR approach in a favourable context.

Background Evaluation of interventions to improve continuity of care across care levels is scarce in Latin America. The Aim to analyse the impact of implemented interventions on the perception of continuity of care of chronic patients in public health care networks of five LA countries (Brazil, Chile, Colombia, Mexico, and Uruguay). Methods Quasi-experimental study (controlled before and after design). Comparable networks, one intervention (IN) and one control (CN) were selected in each country. Baseline (2015) and evaluation (2017) surveys were conducted applying CCAENA questionnaire® to a sample of patients with chronic conditions (392/network; 784/country/year). Result variables: information continuity (exchange of clinical information) and clinical management continuity (repetition of exams, accessibility of primary care (PC) and secondary care (SC), perception of agreement between PC and SC doctors and of collaboration between PC and SC doctors. Descriptive analysis were conducted, and chi-square test was calculated to determine significant changes. Results An increase in the perception of continuity of information between care levels was observed in the IN of all countries, but Colombia. Clinical management continuity: decrease in the repetition of exams and increase in accessibility of consultation with the specialist in all countries but Mexico. The accessibility of PC doctor decreased in the IN in all countries. No differences in the perception of agreement between PC and SC doctors regarding diagnosis, treatment and recommendations were found. The perception of collaboration between PC and SC doctors increased in the five countries. Conclusions Consistent with expected results, the level of perceived information continuity and clinical management continuity increased in the IN, with differences between countries. Further multivariate analyses will be conducted to explore the differences between the IN and CN. Key messages Provides a cross-country comparison of the perception of continuity of care in patients with chronic conditions. Contributes to fill the knowledge gap on the effectiveness of participatory interventions improving continuity of care.

Objective: describe the experience of the proposal, process and results of a training program on qualitative research for nursing teachers based on the constructivist pedagogic model. Method: implementation of a course at a Nursing School in Uruguay from November 3, 2016 to October 12, 2017, in which thirty-nine teachers participated voluntarily. The description of the experience presented in this article is based on the assessment of the course made through participant observation, surveys and a dialogue session with the participants in which the results of the course were discussed. Results: through the implementation of the course, several achievements were accomplished, as well as challenges detected. We would like to highlight the interest received from the course managers and participants in the subject, the nine new research projects, the creation of a bibliographic material, videos and recordings repository, as well as the financial resource mobilization. The challenges were mainly structural and organizational; such as the limited time the participants had to do research and work in teams, the trouble to adopt a critical approach and difficulties with the communication systems. Conclusion: this article contributes to fill the existing gap in qualitative research teaching, and invites to reconsider iniciatives regarding the training of health personnel in the countries of the region, mainly through constructivist and participative models.

Background Despite the effectiveness of Participatory Action Research (PAR) in reducing the gap between evidence and practice, its use to improve care integration is rare. The aim is to analyze the factors influencing the implementation of PAR interventions to improve clinical coordination in public health services networks of Brazil, Chile, Colombia, Mexico and Uruguay. Methods A qualitative, descriptive-interpretative study was conducted in participating healthcare networks of each country. Focus groups and individual semi-structured interviews were conducted to a criteria sample of participants: members of Local Steering Committee (LSC)(29), professionals’ platform (PP)(28), other professionals (49) and managers(28). Thematic content analysis was performed, segmented by country and themes. Results Findings reveal that contextual factors, the PAR process and interventions’ content were determinants in the implementation, interacting over time, and differing among experiences. On the one hand, institutional support (providing the necessary resources) together with the interest of professionals and managers in participating, emerged as influencing factors influenced by other factors related to: the system (alignment with policies; electoral cycle), networks (lack of time due to work overload; precarious employment conditions) and individuals (limited mutual knowledge and mistrust). On the other, some characteristics of the PAR process facilitated institutional support and motivation: professionals’ participation in all activities, design flexibility and shared decision-making - also present when interventions were based on mutual adjustment - the LSC’s leadership and the facilitating role of the research team. Conclusions Evidence is provided that when some contextual elements converge the implementation of interventions through PAR processes can turn into a factor of motivation and cohesion, determinant for the adoption of clinical coordination interventions. Key messages Contributes to fill the knowledge gap in factors influencing the implementation of PAR interventions in healthcare. Provides a framework for analysis and recommendations for their implementation.

Background Evaluation of interventions to improve clinical coordination across care levels is scarce in Latin America. Aim to evaluate the effectiveness of interventions implemented through participatory action research in improving clinical coordination between care levels in public healthcare networks of Brazil, Chile, Colombia, Mexico and Uruguay. Methods Quasi-experimental study (controlled before and after design). Comparable networks, one intervention (IN) and one control (CN), were selected in each country. Baseline (2015) and evaluation (2017) surveys were conducted applying COORDENA® questionnaire to a sample of primary (PC) and secondary (SC) care doctors (174 doctors/network/year). Designed interventions promoted clinical agreement and communication across levels for patients’ follow-up. Outcome variables: a) intermediate: interactional and organizational factors; b) final: experience of clinical management coordination (care consistency and patients’ follow-up) and general perception of coordination between levels. Poisson regression models were estimated. Results Intermediate: interactional factors -personal knowledge and trust on the other care level-increased significantly in Brazil’ and Chile’ INs; and organizational factors -managers’ support- in the INs of Colombia and Mexico. Comparing to CN in 2017, INs of Brazil, Chile, Colombia and Mexico showed significant differences in some factors. Final: care consistency items -agreement over the treatments- improved in the INs of Brazil, Colombia and Uruguay; and patients’ follow-up in the INs of Chile and Mexico. General perception of clinical coordination increased in the INs of Brazil, Colombia and Mexico. Compared to CN in 2017, only Brazil showed significant differences. Conclusions Improvements in intermediate and final care coordination results, consistent with expected results, were observed in all the INs. Reduced implementation time and some process and context factors may have limited their impact. Key messages First study assessing the effectiveness of participatory interventions in improving clinical coordination between care levels in public healthcare networks of Latin America. Results showed changes in the intermediate and final clinical coordination results in the intervention networks. Longer implementation and evaluation times are expected to achieve greater impact.

Objective: To analyse the care continuity across levels of care perceived by patients with chronic conditions in public healthcare networks in six Latin American countries (Argentina, Brazil, Chile, Colombia, Mexico and Uruguay), and to explore associated factors. Method: Cross-sectional study by means of a survey conducted to a random sample of chronic patients in primary care centres of the study networks (784 per country) using the questionnaire Cuestionario de Continuidad Asistencial Entre Niveles de Atención (CCAENA)©. Patients had at least one chronic condition and had used two levels of care in the 6 months prior to the survey for the same medical condition. Descriptive analysis and multivariable logistic regression were carried out. Results: Although there are notable differences between the networks analysed, the results show that chronic patients perceive significant discontinuities in the exchange of clinical information between primary care and secondary care doctors and in access to secondary care following a referral; as well as, to a lesser degree, regarding clinical coherence across levels. Relational continuity with primary care and secondary care doctors and information transfer are positively associated with care continuity across levels; no individual factor is systematically associated with care continuity. Conclusions: Main perceived discontinuities relate to information transfer and access to secondary care after a referral. The study indicates the importance of organisational factors to improve chronic patients’ quality of care. Resumen: Objetivo: Analizar la continuidad asistencial entre niveles de atención percibida por pacientes con enfermedades crónicas en redes sanitarias públicas de seis países latinoamericanos (Argentina, Brasil, Chile, Colombia, México y Uruguay) y explorar los factores asociados. Método: Estudio transversal mediante una encuesta realizada a una muestra aleatoria de pacientes crónicos en los centros de atención primaria de las redes de estudio (784 por país) utilizando el Cuestionario de Continuidad Asistencial Entre Niveles de Atención (CCAENA©). Los pacientes presentaban al menos una afección crónica y habían utilizado dos niveles de atención en los 6 meses anteriores a la encuesta por el mismo motivo. Se realizaron un análisis descriptivo y una regresión logística multivariante. Resultados: Aunque existen diferencias notables entre las redes analizadas, los resultados muestran que los pacientes crónicos perciben discontinuidades significativas en el intercambio de información clínica entre médicos de atención primaria y secundaria, y en el acceso a la atención secundaria tras una derivación, así como, en menor medida, en la coherencia clínica entre niveles. La continuidad de relación con los médicos de atención primaria y secundaria, y la transferencia de información, se asocian de manera positiva con la continuidad asistencial en ambos niveles; ningún factor individual se asocia sistemáticamente con la continuidad asistencial. Conclusiones: Las principales discontinuidades percibidas se relacionan con la transferencia de información y el acceso a la atención secundaria después de una derivación. El estudio indica la importancia de los factores organizativos para mejorar la calidad de la atención de los pacientes crónicos.

Antecedentes: La introduccion de mecanismos de coordinacion de la atencion entre los niveles de atencion tiene como objetivo mejorar la coordinacion clinica y la calidad de la atencion. La evidencia sobre su impacto es limitada y casi inexistente en America Latina. Nuestro objetivo es describir el grado de conocimiento y uso de los mecanismos de coordinacion de la atencion entre los niveles de atencion en seis redes publicas de salud de America Latina. Metodos: Estudio transversal basado en una encuesta que utiliza el cuestionario COORDENA (mayo-octubre de 2015) con medicos de atencion primaria (PC) y atencion secundaria (SC) de redes publicas de salud en Argentina, Brasil, Chile, Colombia, Mexico y Uruguay (348 medicos / pais ) Variables: grado de conocimiento y uso de la coordinacion de la informacion (carta de referencia / respuesta (RRL), informe de alta, telefono, correo electronico) y mecanismos de coordinacion del manejo clinico (guias clinicas compartidas (CG), reuniones conjuntas). Se realizaron analisis descriptivos. Resultados: El conocimiento de los mecanismos de coordinacion de la informacion clinica fue relativamente alto entre los medicos de ambos niveles de atencion y paises (del 44.2 al 100%) y tambien del uso frecuente de RRL (59 al 97.5%). Hubo una mayor variabilidad entre los niveles de atencion y los paises en el uso de informes de alta (12.3% en PC en Colombia a 74.7% en SC en Mexico) y telefono (1.3% en PC en Colombia a 64% en SC en Argentina). El conocimiento y el uso de CG fueron limitados en ambos niveles, excepto en Chile y Mexico. Se observo una variacion considerable en el conocimiento (3.7% Uruguay a 83.7% Chile) y participacion (17.8% Chile a 76.2% Brasil) en reuniones clinicas conjuntas. Las dificultades mas frecuentes en el uso de mecanismos fueron: los medicos no envian los informes RRL o de alta, los CG son dificiles de aplicar y las reuniones conjuntas no cumplen con las expectativas. Conclusiones: Excepto por los mecanismos de coordinacion de la informacion, existe un conocimiento limitado y, ademas de la carta de referencia / respuesta, tambien un uso limitado de los mecanismos de coordinacion de la atencion entre los niveles de atencion en las redes estudiadas. Este problema debe abordarse para mejorar su impacto. Mensajes clave: Esta es la primera encuesta que evalua el mecanismo de coordinacion de la atencion, el conocimiento y el uso por parte de los medicos de atencion primaria y secundaria en las redes publicas de atencion medica de America Latina. Estos resultados revelan un conocimiento limitado y el uso de algunos mecanismos de coordinacion de la atencion y margen de mejora. The Author (s) 2018. Publicado por Oxford University Press en nombre de la Asociacion Europea de Salud Publica. Todos los derechos reservados.

To analyze the level of knowledge and use, and the characteristics of use, of care coordination mechanisms in public healthcare networks of six Latin America countries.

To analyze the level of knowledge and use, and the characteristics of use, of care coordination mechanisms in public healthcare networks of six Latin America countries.Cross-sectional study based on a survey using the COORDENA® questionnaire with primary and secondary care doctors (348 doctors/country) of public healthcare networks in Argentina, Brazil, Chile, Colombia, Mexico and Uruguay (May-October 2015). Analyzed variables: degree of knowledge and use of information coordination (referral/reply letter, discharge report, phone, e-mail) and of clinical management coordination (shared clinical guidelines, joint meetings) mechanisms. Descriptive analyses were conducted.Knowledge of clinical information coordination mechanisms was high in both care levels and analyzed networks as was the use of referral/reply letter. There was greater variability in the use of discharge reports (from 40.0% in Brazil to 79.4% in Mexico) and, except for Argentina, a low reception reported by primary care doctors stands out (12.3% in Colombia and 55.1% in Uruguay). In contrast, knowledge of clinical management coordination mechanisms was limited, especially among secondary care doctors. It is noteworthy, however, that adherence to clinical guidelines was high (from 83.1% in Mexico to 96.8% in Brazil), while participation in joint meetings varied widely (from 23.7% in Chile to 76.2% in Brazil). The difficulties reported in the use of the mechanisms are related to structural and organizational factors.The limited knowledge and use of coordination mechanisms shows insufficient diffusion and implementation. Strategies to increase its use are needed, including the related factors.

An adequate use of referral and reply letters - the main form of communication between primary care (PC) and out-patient secondary care (SC) - helps to avoid medical errors, test duplications and delays in diagnosis. However, it has been little studied to date in Latin America. The aim is to determine the level and characteristics of PC and SC doctors' use of referral and reply letters and to explore influencing factors in public healthcare networks of Argentina, Brazil, Chile, Colombia, Mexico and Uruguay. A cross-sectional study was conducted through a survey of PC and SC doctors working in public healthcare networks (348 doctors per country). The COORDENA questionnaire was applied to measure the frequency of use and receipt of referral and reply letters, quality of contents, timeliness and difficulties in using them. Descriptive analyses were conducted and a multivariate logistic regression model was generated to assess the relationship between frequent use and associated factors. The great majority of doctors claim that they send referral letters to the other level. However, only half of SC doctors (a higher proportion in Chile and Mexico) report that they receive referral letters and

CUESTIONARIO DE CONTINUIDAD ENTRE NIVELES DE ATENCIÓN (CCAENA-ARGENTINA)

CUESTIONARIO DE CONTINUIDAD ENTRE NIVELES DE ATENCIÓN (CCAENA-COLOMBIA)

Improving coordination between primary care (PC) and secondary care (SC) has become a policy priority in recent years for many Latin American public health systems looking to reinforce a healthcare model based on PC. However, despite being a longstanding concern, it has scarcely been analyzed in this region. This paper analyses the level of clinical coordination between PC and SC experienced by doctors and explores influencing factors in public healthcare networks of Argentina, Brazil, Chile, Colombia, Mexico and Uruguay. A cross-sectional study was carried out based on a survey of doctors working in the study networks (348 doctors per country). The COORDENA questionnaire was applied to measure their experiences of clinical management and information coordination, and their related factors. Descriptive analyses were conducted and a multivariate logistic regression model was generated to assess the relationship between general perception of care coordination and associated factors. With some differences between countries, doctors generally reported limited care coordination, mainly in the transfer of information and communication for the follow-up of patients and access to SC for referred patients, especially in the case of PC doctors and, to a lesser degree, inappropriate clinical referrals and disagreement over treatments, in the case of SC doctors. Factors associated with a better general perception of coordination were: being a SC doctor, considering that there is enough time for coordination within consultation hours, job and salary satisfaction, identifying the PC doctor as the coordinator of patient care across levels, knowing the doctors of the other care level and trusting in their clinical skills. These results provide evidence of problems in the implementation of a primary care-based model that require changes in aspects of employment, organization and interaction between doctors, all key factors for coordination. © 2017 The Authors

"Introduccion Aunque la fragmentacion en la provision de atencion medica se considera un obstaculo importante para una atencion efectiva, la evidencia sobre las mejores practicas en la coordinacion de la atencion en America Latina es escasa. El objetivo del proyecto Equity-LA financiado por el 7PM es evaluar la efectividad de diferentes estrategias de integracion de la atencion para mejorar la coordinacion entre los niveles de atencion y la calidad de la atencion relacionada en seis sistemas de atencion medica: Argentina, Brasil, Chile, Colombia, Mexico y Uruguay. Metodos y analisis: Un estudio cuasi experimental controlado antes y despues que toma un enfoque de investigacion de accion participativa. En cada pais, se seleccionaron dos redes sanitarias comparables (intervencion y control). El estudio consta de cuatro fases: 1) Estudio de linea de base para establecer el desempeno de la red en la coordinacion y continuidad de la atencion, utilizando a) metodos cualitativos: entrevistas semiestructuradas y grupos focales de administradores de salud, profesionales y usuarios; yb) metodos cuantitativos: dos encuestas por cuestionario con muestras de 173 medicos de atencion primaria y secundaria y 392 usuarios con afecciones cronicas por red; tamano de muestra calculado para detectar una diferencia de proporcion de 15% y 10%, antes y despues de la intervencion (? = 0.05; ? = 0.2 en una prueba de dos lados); 2) Seleccion participativa ascendente, diseno e implementacion de estrategias de atencion compartida, un proceso dirigido por el comite directivo local; 3) Evaluacion de la efectividad de las intervenciones que aplican el mismo diseno que en el estudio de linea de base y los factores asociados; 4) Analisis comparativo entre paises. Resultados y relevancia El proyecto generara evidencia para informar la formulacion de politicas sobre las mejores practicas de integracion entre la atencion primaria y secundaria en diferentes tipos de sistemas de salud en America Latina, con especial referencia a las enfermedades cronicas, y sobre el efecto de los nuevos enfoques organizacionales en la calidad de la atencion, en diferentes contextos de asistencia sanitaria tambien relevantes para los sistemas sanitarios europeos. Mensajes clave Existe poca evidencia sobre las mejores practicas en coordinacion de la atencion en America Latina Los resultados sobre la coordinacion de la atencion pueden depender del factor contextual y del proceso. The Author 2015. Publicado por Oxford University Press en nombre de la Asociacion Europea de Salud Publica. Todos los derechos reservados."

CUESTIONARIO DE CONTINUIDAD ENTRE NIVELES DE ATENCIÓN (CCAENA-URUGUAY)

CUESTIONARIO DE CONTINUIDAD ENTRE NIVELES DE ATENCIÓN (CCAENA-MX)

QUESTIONÁRIO DE CONTINUIDADE ENTRE NÍVEIS DE ATENÇÃO (CCAENA-BRASIL)

CUESTIONARIO DE CONTINUIDAD ENTRE NIVELES DE ATENCIÓN (CCAENA-CHILE)

Introduction Although fragmentation in the provision of healthcare is considered an important obstacle to effective care, there is scant evidence on best practices in care coordination in Latin America. The aim is to evaluate the effectiveness of a participatory shared care strategy in improving coordination across care levels and related care quality, in health services networks in six different healthcare systems of Latin America. Methods and analysis A controlled before and after quasi-experimental study taking a participatory action research approach. In each country, two comparable healthcare networks were selected—intervention and control. The study contains four phases: (1) A baseline study to establish network performance in care coordination and continuity across care levels, using (A) qualitative methods: semi-structured interviews and focus groups with a criterion sample of health managers, professionals and users; and (B) quantitative methods: two questionnaire surveys with samples of 174 primary and secondary care physicians and 392 users with chronic conditions per network. Sample size was calculated to detect a proportion difference of 15% and 10%, before and after intervention (α=0.05; β=0.2 in a two-sided test); (2) a bottom-up participatory design and implementation of shared care strategies involving micro-level care coordination interventions to improve the adequacy of patient referral and information transfer. Strategies are selected through a participatory process by the local steering committee (local policymakers, health care network professionals, managers, users and researchers), supported by appropriate training; (3) Evaluation of the effectiveness of interventions by measuring changes in levels of care coordination and continuity 18 months after implementation, applying the same design as in the baseline study; (4) Cross-country comparative analysis. Ethics and dissemination This study complies with international and national legal stipulations on ethics. Conditions of the study procedure were approved by each country9s ethical committee. A variety of dissemination activities are implemented addressing the main stakeholders. Registration No.257 Clinical Research Register of the Santa Fe Health Department, Argentina.

Die Kommunalisierung der Gesundheitsfürsorge Die Armutsenklaven und das Auftreten alter und neuer Epidemien verändern Rahmen und Größenordnung öffentlicher Gesundheitsfürsorge. Die Wiederkehr von Begriffen wie Risikomilieu rechtfertigen die Mobilisierung lokaler, vor allem kommunaler Strukturen. Die hygienischen Maßnahmen des letzten Jahrhunderts und die späteren Heilstrategien ergänzt dieser neue kommunale Aufgabenbereich um variable Instanzen, deren Interventionsspielraum von zerrütteten sozialen Strukturen bis zur medizinischen Nothilfe reicht., Making public health care municipal Pockets of poverty and the upsurge of old and new epidemics has changed the framework and scale of public health care. The revival of concepts such as groups at risk has justified initiatives being taken by local communities, especially by urban governments. This new urban situation adds various systems of institutional cooperation acting on both the desocialization process and medical emergencies to the past century's hygienism and curative policies., Les enclaves de pauvreté et la résurgence d'épidémies anciennes et nouvelles modifient les cadres et les échelles de la santé publique. Le retour des notions de milieu à risques justifie la mobilisation des collectivités locales, notamment les municipalités urbaines. A l'hygiénisme du siècle dernier et aux politiques curatives, cette nouvelle conjoncture urbaine ajoute des configurations institutionnelles variables qui se mobilisent autant sur les processus de désocialisation que sur l'urgence médicale., La municipalización de la salud pública Los enclaves de pobreza y la resurgimiento de epidemias antiguas y nuevas modifican los marcos y escalas de la salud pública. El retorno de las nociones de entorno sujeto a riesgo justifica la movilización de las administraciones locales, especialmente las municipalidades urbanas. Al higienismo del siglo pasado y a las políticas curativas, esta nueva coyuntura urbana añade configuraciones institucionales variables que se movilizan tanto sobre los procesos de desocialización como sobre la urgencia médica., Bertolotto Fernando. La municipalisation de la santé publique : Les problèmes sanitaires d'une société en crise sociale et économique. In: Les Annales de la recherche urbaine, N°73, 1996. Ville et santé publique. pp. 67-73.

•First comparative analysis of doctor care coordination experience in Latin America. •Limited information transfer and communication across care levels in all countries. •Disagreement over treatments and inappropriate referrals mainly in Chile and Mexico. •Limited overall coordination across levels mainly in Brazil, Chile and Mexico. •Associated factors: identifying PC doctor as care coordinator, knowledge and trust.