Atenção à saúde das pessoas após o transplante renal: modelo de atenção crônica

Abstract

The general objective was to know the organization of health care for people with chronic renal failure after renal transplantation. This is a qualitative research developed in three cities in South of Rio Grande do Sul (Pelotas, Rio Grande, and São Lourenço do Sul). The participants were people linked to the nephrology services chosen in these cities, who performed kidney transplantation, as well as health providers and managers who worked in the Municipal and State Health Departments. In order to collect the data, we used questionnaires adapted from the Assessment of Chronic Illness Care and Patient Assessment of Chronic Illness Care. The interviews were recorded in audio, and when transcribed, the data was managed and organized, using the Ethnography Software for the analysis of directed content. The Research Ethics Committee of the Holy House of Mercy Hospital in Pelotas approved the present research, under the number 1.548.228. In the results, the characterization of the people, the professionals, and the managers are presented. Afterwards, the data was explained in five categories: Organization of health services for the care of people after kidney transplantation; Health care provided by professionals and/or health services to persons after renal transplantation; The support network of people after kidney transplantation; Self-care after renal transplantation at treatment adherence; and System of clinical information of people after renal transplantation in health services. It was understood how nephrology services and transplantation centers are organized to assist people after renal transplantation, such as the provision of immunosuppressive medication, clinical review visits and other specialties in the health field, the provision of support groups and permanent education, among others. In the case of care, verbal and/or written guidelines, clinical consultations, the dosage of immunosuppressive medications and monitoring of laboratory test results were the most offered by professionals and/or health services. Regarding the composition of the support network of people after kidney transplantation, it was identified that the nuclear or extensive family was the most cited. Regarding the orientation to self-care for adherence to renal transplant treatment, the care to be followed was highlighted. In what concerns the organization, registration form and the process of storage of clinical information, nephrology services, and transplantation centers, we highlighted the existing types of medical records, the responsibility of the referral service and the non-sharing of data. The findings led to a reflection on the role of professionals and managers in the consolidation of the Chronic Attention Model. It was also observed that care and health management actions make it possible to promote continuity of care in the person with renal transplantation, guaranteeing the quality of the treatment and the survival of the transplanted organ.