The influence of organizational models on the implementation of internet-based cognitive behavior therapy in primary care: A mixed methods study using the RE-AIM framework.

Background: Internet-Based Cognitive Behavioral Therapy (iCBT) holds great potential in addressing mental health issues, yet its real-world implementation poses significant challenges. While prior research has predominantly focused on centralized care models, this study explores the implementation of iCBT in the context of decentralized organizational structures within the Swedish primary care setting, where all interventions traditionally are delivered at local Primary Care Centers (PCCs). Aim: This study aims to enhance our understanding of iCBT implementation in primary care and assess the impact of organizational models on the implementation's outcome using the RE-AIM (Reach, Effectiveness, Adoption, Implementation, Maintenance) framework. Method: A mixed-methods research design was employed to identify the factors influencing iCBT implementation across different levels, involving patients, therapists and managers. Data spanning two years was collected and analyzed through thematic analysis and statistical tests. The study encompassed 104 primary care centers, with patient data (n = 1979) sourced from the Swedish National Quality Register for Internet-Based Psychological Treatment (SibeR). Additionally, 53 iCBT therapists and 50 PCC managers completed the Normalization Measure Development Questionnaire, and 15 leaders participated in interviews. Results: Our investigation identified two implementation approaches, one concentrated and one decentralized. Implementation effectiveness was evident through adherence rates suggesting that iCBT is a promising approach for treating mental ill-health in primary care, although challenges were observed concerning patient assessment and therapist drift towards unstructured treatment. Mandatory implementation, along with managerial and organizational support, positively impacted adoption. Results vary in terms of adherence to established protocols, with therapists working in concentrated model showing a significantly higher percentage of registration in the quality register SibeR (X2 (1, N = 2973) = 430.5774, p = 0.001). They also showed significantly higher means in cognitive participation (Z = -2.179, p = 0.029) and in reflective monitoring (Z = -2.548, p = 0.011). Discussion: Overall, the study results demonstrate that iCBT, as a complex and qualitatively different intervention from traditional psychological treatment, can be widely implemented in primary care settings. The study's key finding highlights the substantial advantages of the concentrated organizational model. This model has strengths in sustainability, encourages reflective monitoring among therapists, the use of quality registers, and enforces established protocols. Conclusion: In conclusion, this study significantly contributes to the understanding of the practical aspects associated with the implementation of complex internet interventions, particularly in the context of internet-based cognitive-behavioral therapy (iCBT). The study highlights that effective iCBT integration into primary care requires a multifaceted approach, taking into account organizational models, robust support structures, and a commitment to maintaining quality standards. By emphasizing these factors, our research aims to provide actionable insights that can enhance the practicability and real-world applicability of implementing iCBT in primary care settings.

Patterns of major trauma admissions to a level 1 trauma centre: A five year database analysis.

INTRODUCTION: It is only in recent years that major trauma systems and networks have been operating in the UK. High-quality data is available from the Trauma Audit and Research Network (TARN) database, enabling regional analysis. Our aim was to analyse Trauma Team Activations within the Cheshire and Merseyside major trauma network and discuss the implications of these data on resource allocation, training and trauma prevention. METHODS: A retrospective analysis was performed for all patients requiring Trauma Team Activation (TTA) at a category one adult Major Trauma Centre (MTC) who were submitted to the TARN database from the 1st January 2015 to the 1st January 2020. Data collected included the date and time of arrival, location of injury and Injury Severity Score (ISS) in addition to routine demographic data. Dates of major sporting events and school holidays were obtained. RESULTS: 4811 patients were identified. The median age was 57 years; 65.8 % were male. The mean frequency of TTAs was 18.5 per week. Patterns identified include annual peaks during the summer months, October and December, weekly peaks on Thursdays and Sundays and daily peaks between 16:00 and 23:59 with 45.0 % of TTAs occurring between these hours. There were 5.9 additional TTAs per week during the Isle of Man TT races. The median ISS increased from 14 to 23 for TT race TTAs and from 14 to 36 for Manx Grand Prix TTAs. Those injured during the TT races were twice as likely to require surgery and those injured during the MGP required five additional days in intensive care. School holidays did not independently affect major trauma volumes. CONCLUSIONS: Major trauma in Cheshire and Merseyside did follow distinct patterns according to calendar month, day and time. Major motorsport increased trauma volumes and severity; school holidays did not. Such analysis could enable Major Trauma Centres to tailor the supply of trauma services to meet a predictable local demand for the benefit of our staff and patients.

Management Approaches to Health and Safety at Work during Prevention Intervention Planning.

This work deals with a systematic review of the literature data concerning the theme of integrated approaches to occupational health and safety management, with particular reference to the programming of assistance plans, which guide companies' organizational choices by also addressing the principles of Total Worker Health. In the current regulatory framework on this issue, the UNI ISO 45001: 2018 standard "Occupational health and safety management systems-Requirements and guidance for use" (published on 12 March 2018)" assumes relevance, defining dynamic approaches to occupational health and safety management systems-paying particular attention to external contextual factors that may influence corporate organizational decisions. The adoption of these systems is not mandatory but allows companies to fulfill their duties in terms of health and safety at work through an organizational approach aimed at the awareness, involvement, and participation of all subjects of the company prevention system, progressing past the phase of mere technological and prescriptive approaches towards a holistic vision of prevention that places the person at the center of preventive actions. In this context, the role of institutional networks and socio-economic partnerships assumes particular importance via the activation of territorial assistance interventions to support companies aimed at improving risk management levels. To this end, the importance of verifying the effectiveness of assistance interventions emerges from the scientific debate using indicators such as quantitative indicators aimed at measuring the performance of all phases of an intervention, with particular attention to their effects in terms of the improved solutions developed.

A cross-organizational Lean deployment in an Italian regional healthcare system.

PURPOSE: This study explores how Lean was deployed in several hospitals in the Apulia region in Italy over 3.5 years. DESIGN/METHODOLOGY/APPROACH: An exploratory qualitative design was drawn up based on semi-structured interviews. FINDINGS: The drivers of Lean in hospitals were to increase patient satisfaction and improve workplace well-being by eliminating non-value-add waste. The participants highlighted three key elements of the pivotal implementation stages of Lean: introduction, spontaneous and informal dissemination and strategic level implementation and highlighted critical success and failure factors that emerged for each of these stages. During the introduction, training and coaching from an external consultant were among the most impactful factors in the success of pilot projects, while time constraints and the adoption of process analysis tools were the main barriers to implementation. The experiences of the Lean teams strongly influence the process of spontaneous dissemination aided by the celebration of project results and the commitment of the departmental hospital heads. PRACTICAL IMPLICATIONS: Lean culture can spread to allow many projects be conducted spontaneously, but the Lean paradigm can struggle to be adopted strategically. Lean in healthcare can fail because of the lack of alignment of Lean with leadership in healthcare and with their strategic vision, a lack of employees' project management skills and crucially the absence of a Lean steering committee. ORIGINALITY/VALUE: The absence of managerial expertise and a will to support Lean implementation do not allow for systemic adoption of Lean. This is one of the first and largest long-term case studies on a Lean cross-regional multi-hospital application in healthcare.

Cuidados de enfermagem omissos na perceção da equipa: Uma análise das razões / The nursing team's perspective on missed nursing care: An analysis of the reasons / Cuidados de enfermería omitidos en la percepción del personal: Un análisis de las razones

Resumo Enquadramento: Diante de múltiplas solicitações e recursos insuficientes, os profissionais de enfermagem podem não executar alguns cuidados requeridos. Objetivos: Identificar os cuidados de enfermagem omissos, as razões atribuídas pelos profissionais de enfermagem e verificar se as razões diferem entre as categorias profissionais. Metodologia: Estudo descritivo, transversal, utilizando o instrumento MISSCARE-Brasil numa amostra por conveniência de 115 participantes, distribuídos entre 48 enfermeiros e 67 técnicos em enfermagem. Resultados: Os participantes apresentaram média de idade de 34,9 anos, predominando o sexo feminino, 88,6%. Os cuidados de enfermagem mais omitidos foram a deambulação três vezes por dia ou conforme prescrito, 58,3%; a participação em discussão da equipa interdisciplinar sobre a assistência ao paciente, 55,6%; e a oferta das refeições para os pacientes que se alimentam sozinhos, 53,1%. As principais razões para omissão foram relacionadas os domínios "Recursos Materiais" e "Laborais". Conclusão: Os recursos materiais e laborais influenciam na frequência de cuidados de enfermagem omissos, apesar das justificações diferenciadas para omissão do cuidado entre enfermeiros e técnicos em enfermagem.

Abstract Background: Faced with multiple requests and insufficient resources, the nursing professionals may not perform some required care. Objectives: Identify the missing nursing care, the reasons attributed by nursing professionals and check whether the reasons differ between professional categories. Methodology: A descriptive, cross-sectional study using the MISSCARE-Brazil instrument in a convenience sample of 115 participants, distributed between 48 nurses and 67 nursing technicians. Results: Participants had a mean age of 34.9 years, predominantly female, 88.6%. The most omitted nursing care were walking three times a day or as prescribed, 58.3%; the participation in the discussion of the interdisciplinary team about patient care, 55.6% and the offer of meals to patients who eat alone, 53.1%. The main reasons for the omission were related to the "Material Resources" and "Laboratory" domains. Conclusion: material and labor resources influence the frequency of missing nursing care, despite different justifications for omission of care among nurses and nursing technicians.

Resumen Marco contextual: Ante la multitud de solicitudes y la insuficiencia de recursos, los profesionales de enfermería pueden no realizar algunos de los cuidados necesarios. Objetivos: Identificar los cuidados de enfermería omitidos, las razones atribuidas por los profesionales de enfermería y verificar si las razones difieren entre las categorías profesionales. Metodología: Estudio descriptivo, transversal, utilizando el instrumento MISSCARE-Brasil en una muestra de conveniencia de 115 participantes, distribuidos entre 48 enfermeros y 67 técnicos de enfermería. Resultados: Los participantes tenían una edad media de 34,9 años, con predominio del sexo femenino, el 88,6%. Los cuidados de enfermería más omitidos fueron los paseos tres veces al día o según lo prescrito, el 58,3%; la participación en las discusiones con el equipo interdisciplinario sobre los cuidados del paciente, el 55,6%; y la provisión de comidas para los pacientes que se alimentan solos, el 53,1%. Los principales motivos para omitirlos estaban relacionados con los ámbitos "Recursos materiales" y "Mano de obra". Conclusión: Los recursos materiales y laborales influyen en la frecuencia de los cuidados de enfermería omitidos, a pesar de las diferentes justificaciones para omitirlos entre los enfermeros y los técnicos de enfermería.

Improving the Integration between Palliative Radiotherapy and Supportive Care: A Narrative Review.

Palliative radiotherapy (PRT) is known to be effective in relieving cancer related symptoms. However, many studies and clinical practice show several barriers hindering its use and worsening the quality of patient support during PRT. Various solutions were proposed to overcome these barriers: training on PRT for supportive and palliative care specialists and training on palliative care for radiation oncologists, and introduction of pathways and organizational models specifically dedicated to PRT. Evidence on innovative organizational models and mutual training experiences is few and sparse. Therefore, the aim of this literature review is to present a quick summary of the information available on improving the PRT quality through training, new pathways, and innovative organizational models. The majority of studies on the integration of PRT with other palliative and supportive therapies present low levels of evidence being mostly retrospective analyses. However, it should be emphasized that all reports uniformly showed advantages coming from the integration of PRT with supportive therapies. To actively participate in the integration of PRT and palliative care, providing comprehensive support to the needs of patients with advanced cancer, radiation oncologists should not only plan PRT but also: (i) assess and manage symptoms and stress, (ii) rapidly refer patients to specialists in management of more complex symptoms, and (iii) participate in multidisciplinary palliative care teams. To this end, improved education in palliative care both in residency schools and during professional life through continuous medical education is clearly needed. In particular, effective training is needed for radiotherapy residents to enable them to provide patients with comprehensive palliative care. Therefore, formal teaching of adequate duration, interactive teaching methods, attendance in palliative care services, and education in advanced palliative care should be planned in post-graduated schools of radiotherapy.

A Formal Model for the FAIR4Health Information Architecture.

In the EU project FAIR4Health, a ETL pipeline for the FAIRification of structured health data as well as an agent-based, distributed query platform for the analysis of research hypotheses and the training of machine learning models were developed. The system has been successfully tested in two clinical use cases with patient data from five university hospitals. Currently, the solution is also being considered for use in other hospitals. However, configuring the system and deploying it in the local IT architecture is non-trivial and meets with understandable concerns about security. This paper presents a model for describing the information architecture based on a formal approach, the 3LGM metamodel. The model was evaluated by the developers. As a result, the clear separation of tasks and the software components that implement them as well as the rich description of interactions via interfaces were positively emphasized.

Transformation of health care and the new model of care in Saudi Arabia: Kingdom's Vision 2030.

The Kingdom of Saudi Arabia espoused "Vision 2030" as a strategy for economic development and national growth. The vision demonstrated the Kingdom's objectives to become a pioneer nation globally by achieving three main goals: a vibrant society, a thriving economy, and an ambitious nation. To fulfill this, the Kingdom launched a national transformation program (NTP) as outlined in "vision 2030" in June 2016. The health care transformation is one of the eight themes of the NTP's. The history of health care facilities in the Kingdom is almost a century. Although the Kingdom has made notable progress in improving its population's health over recent decades, it needs to modernize the health care system to reach the "vision 2030" goal. This article aims to describe the new Model of Care (MOC) according to the recent Saudi health care transformation under the Kingdom's vision 2030. The MOC concept started with understanding the current state and collecting learnings. It is based on the six systems of care (SOC)- keeping well, planned procedure, women & children, urgent problems, chronic conditions, and the last phase of life. The SOC is cut across different "service layers" to support people's stay well and efficiently get them healthy again when they need care. The new MOC describes a total of forty-two interventions, of which twenty-seven split across the six SOC and the rest fifteen cut-across the multiple SOC. Implementation of all MOC interventions will streamline the Saudi health care system to embrace the Kingdom's "vision 2030".

Organizational Models for Cardiac Implantable Electronic Device Remote Monitoring: Current and Future Directions.

This review provides an overview of the literature on the organization, staffing, and structure of remote monitoring (RM) clinics, primarily from countries in Western Europe and United States, as well as the challenges, considerations, and future directions for RM clinic models of care. Using a current case example of an RM clinic in the Midwestern United States, this document provides key information from the viewpoint of a clinic undergoing a shift in workflow. Finally, this review distills key considerations for RM management for electrophysiology clinics, vendors and industry, and policy makers.

Design and implementation of a temporary emergency department-intensive care unit patient care model during the COVID-19 pandemic surge.

The ongoing pandemic of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has resulted in rapid surges of critically ill patients infected with coronavirus disease 2019 (COVID-19) pneumonia presenting to the emergency department (ED) and requiring ICU admission nationwide. Despite adaptations in critical care personnel staffing, bed availability and supply provision, many inpatient ICUs have become acutely crowded, leading to boarding of critically ill patients with COVID-19 and other diseases in the ED. To address this scenario at our urban, safety net, tertiary care institution in the spring of 2020, we designed and implemented a temporary "emergency department-intensive care unit" (ED-ICU) patient care service. Critical care-trained emergency physicians took call and came into the hospital overnight/on weekends to provide bedside treatment to admitted ICU patients boarding for prolonged periods in our ED. In this manuscript, we describe the creation and execution of the ED-ICU service and the characteristics and management of the patients who received care under this model.

Comprehensive Model for Physical and Cognitive Frailty: Current Organization and Unmet Needs.

Aging is characterized by the decline and deterioration of functional cells and results in a wide variety of molecular damages and reduced physical and mental capacity. The knowledge on aging process is important because life expectancy is expected to rise until 2050. Aging cannot be considered a homogeneous process and includes different trajectories characterized by states of fitness, frailty, and disability. Frailty is a dynamic condition put between a normal functional state and disability, with reduced capacity to cope with stressors. This geriatric syndrome affects physical, neuropsychological, and social domains and is driven by emotional and spiritual components. Sarcopenia is considered one of the determinants and the biological substrates of physical frailty. Physical and cognitive frailty are separately approached during daily clinical practice. The concept of motoric cognitive syndrome has partially changed this scenario, opening interesting windows toward future approaches. Thus, the purpose of this manuscript is to provide an excursus on current clinical practice, enforced by aneddoctical cases. The analysis of the current state of the art seems to support the urgent need of comprehensive organizational model incorporating physical and cognitive spheres in the same umbrella.

Shaping the Future of Rare Diseases after a Global Health Emergency: Organisational Points to Consider.

The unexpected outbreak of the COVID-19 disease had significant and enormous repercussions on the healthcare systems, such as the need to reorganise healthcare organisations in order to concentrate resources needed to the care of COVID-19 patients and to respond in general to this health emergency. Due to these challenges, the care of several chronic conditions was in many cases discontinued and patients and healthcare professionals treating these conditions had to cope with this new scenario. This was the case of the world rare diseases (RDs) that had to face this global emergency despite the vulnerability of people with RDs and the well-known need for high expertise required to treat and manage them. The numerous lessons learned so far regarding health emergencies and RDs should represent the basis for the establishment of new healthcare policies and plans aimed at ensuring the preparedness of our health systems in providing appropriate care to people living with RDs in the case of eventual new emergencies. This paper aims at providing pragmatic considerations that might be useful in designing future actions to create or optimise existing organisational models for the care of RDs in case of future emergencies or any other situation that might threaten the provision of routine care. These policies and plans should benefit from the multi-stakeholder RDs networks (such as the European Reference Networks), that should join forces at European, national, and local levels to minimise the economic, organisational, and health-related impact and the negative effects of potential emergencies on the RDs community. In order to design and develop these policies and plans, a decalogue of points to consider were developed to ensure appropriate care for people living with RDs in the case of eventual future health emergencies.

Professional identity of allied health staff associated with a major health network organizational restructuring.

Maintenance of professional identity, particularly during periods of organizational restructuring, is critical within modern complex healthcare systems as professional identity contributes to the psychological well-being of staff and leaders. This study aimed to evaluate change in professional identity of allied health staff associated with a major health network organizational restructuring in Australia. Data were collected from allied health staff in 2017 and 2019, before (n = 226) and after (n = 197) the restructuring. An online questionnaire including the 10-question Brown's Group Identification Scale that considers the strength of professional identity of the individual with their own professional group was used. Professional identity of allied health staff was high before and after the organizational restructuring, although several individual statements, and overall professional identity, declined significantly post-restructuring. It was difficult to attribute these changes solely to the restructuring due to some differences in demographic characteristics between the two cohorts. Future studies should seek to understand the effect of other workplace factors on the professional identity of allied health staff. Further research could also investigate allied health professional identity to understand its importance within contemporary healthcare.

Cardiac intensive care in Portugal: The time for change. / Cuidados intensivos cardíacos em Portugal: projetar a mudança.

In recent years, the number of patients requiring acute cardiac care has increased, with progressively more complex cardiovascular conditions, often complicated by acute or chronic non-cardiovascular comorbidities, which affects the management and prognosis of these patients. Coronary care units have evolved into cardiac intensive care units, which provide highly specialized health care for the critical heart patient. In view of the limited human and technical resources in this area, we consider that there is an urgent need for an in-depth analysis of the organizational model for acute cardiac care, including the definition of the level of care, the composition and training of the team, and the creation of referral networks. It is also crucial to establish protocols and to adopt safe clinical practices to improve levels of quality and safety in the treatment of patients. Considering that acute cardiac care involves conditions with very different severity and prognosis, it is essential to define the level of care to be provided for each type of acute cardiovascular condition in terms of the team, available techniques and infrastructure. This will lead to improvements in the quality of care and patient prognosis, and will also enable more efficient allocation of resources.

Out-of-hours primary care in 26 European countries: an overview of organizational models.

BACKGROUND: Various models exist to organize out-of-hours primary care (OOH-PC). We aimed to provide an up-to-date overview of prevailing organizational models in the European Union (EU), implemented changes over the last decade and future plans. This baseline overview may provide information for countries considering remodelling their OOH-PC system. METHODS: A cross-sectional web-based questionnaire among 93 key informants from EU countries, Norway and Switzerland. Key informants with expertise in the field of primary health care were invited to participate. Themes in the questionnaire were the existing organizational models for OOH-PC, model characteristics, major organizational changes implemented in the past decade and future plans. RESULTS: All 26 included countries had different coexisting OOH-PC models, varying from 3 to 10 models per country. 'GP cooperative was the dominant model in most countries followed by primary care centre and rota group'. There was a large variation in characteristics between the models, but also within the models, caused by differences between countries and regions. Almost all countries had implemented changes over the past 10 years, mostly concerning the implementation of telephone triage and a change of organizational model by means of upscaling and centralization of OOH-PC. Planned changes varied from fine-tuning the prevailing OOH-PC system to radical nationwide organizational transitions in OOH-PC. CONCLUSIONS: Different organizational models for OOH-PC exist on international and national level. Compared with a decade ago, more primary care-oriented organizational models are now dominant. There is a trend towards upscaling and centralization; it should be evaluated whether this improves the quality of health care.

Management Principles to Drive the Creation of a 21st Century Medical School.

Introduction: There are currently no data, blueprints, best practices, or financial models available to guide the creation of a new medical school. Yet, the United States is experiencing unprecedented growth of new allopathic medical schools. Findings: This article brings logic to the process. It converts the complexity of what is often regarded as an administrative exercise into the first published framework of management principles. Those principles were then translated into a process map and a financial optimization model. All three elements can be successfully implemented for establishing an accredited, value-driven medical education program that minimizes time from inception to implementation, and ensures sustainability over time. Outcomes: This case report provides a blueprint for planning and implementation of a new medical school. Outcomes include both process and optimization models, as well as valuable insights that have utility when considering a new medical school to mitigate the projected nationwide shortage of physicians.

Effect of organizational models of provider-initiated testing and counseling (PITC) in health facilities on adult HIV testing coverage in sub-Saharan Africa.

The purpose of this paper is to identify which Provider-Initiated HIV Testing and Counseling (PITC) organizational models are the most efficient to maximize testing coverage. We conducted a systematic literature review to identify published articles that evaluated routine PITC programs implemented in adult health facilities in Sub-Saharan Africa. We considered only articles measuring PITC offer, PITC acceptability and PITC coverage. Adjusted meta-regression models were performed to measure the association between PITC offer, acceptability and coverage with PITC organizational model. A total of 30 articles were included in the meta-analysis. Overall, 85.4% [95%CI: 77.2-93.5] of patients were offered a test, and 87.1% [82.4-91.7] accepted the test resulting in a PITC coverage of 74.3% [66-82.6]. Four types of PITC organizational models were identified: PITC initiated and performed during the consultation (model A), PITC initiated before consultation (model B), PITC referred on-site (model C) and PITC referred off-site (model D). Compared to model A, model B had a similar coverage (aOR: 1.02 [0.82-1.26]). However, coverage was lower for model C (aOR: 0.81 [0.68-0.97]) and model D (aOR: 0.58 [0.44-0.77]). Initiating the testing process before or during medical consultation is recommended for maximizing testing coverage among patients.

The Italian INTERCEPTOR Project: From the Early Identification of Patients Eligible for Prescription of Antidementia Drugs to a Nationwide Organizational Model for Early Alzheimer's Disease Diagnosis.

Alzheimer's disease is the most common age-related neurodegenerative disorder and its burden on patients, families, and society grows significantly with lifespan. Early modifications of risk-enhancing lifestyles and treatment initiation expand personal autonomy and reduce management costs. Many clinical trials with potentially disease-modifying drugs are devoted to mild cognitive impairment (MCI) prodromal-to-Alzheimer's disease. The identification of biomarkers for early diagnosis may thus be crucial for early intervention and identification of high-risk subjects, the most appropriate target of new drugs as soon as they will be discovered. INTERCEPTOR is a strategic project by the Italian Ministry of Health and the Italian Medicines Agency (AIFA), aiming to validate the best combination (highly accurate, non-invasive, available on the whole national territory and financially sustainable) of biomarkers and organizational model for early diagnosis. 500 MCI subjects will be enrolled at baseline and followed-up for 3 years for at least 400 of them in order to define a "hub & spoke" nationwide model with recruiting (spokes) centers for MCI identification and expert (hubs) centers for risk diagnosis.

Doctors' opinions on clinical coordination between primary and secondary care in the Catalan healthcare system.

OBJECTIVE: To analyse doctors' opinions on clinical coordination between primary and secondary care in different healthcare networks and on the factors influencing it. METHODS: A qualitative descriptive-interpretative study was conducted, based on semi-structured interviews. A two-stage theoretical sample was designed: 1) healthcare networks with different management models; 2) primary care and secondary care doctors in each network. Final sample size (n = 50) was reached by saturation. A thematic content analysis was conducted. RESULTS: In all networks doctors perceived that primary and secondary care given to patients was coordinated in terms of information transfer, consistency and accessibility to SC following a referral. However, some problems emerged, related to difficulties in acceding non-urgent secondary care changes in prescriptions and the inadequacy of some referrals across care levels. Doctors identified the following factors: 1) organizational influencing factors: coordination is facilitated by mechanisms that facilitate information transfer, communication, rapid access and physical proximity that fosters positive attitudes towards collaboration; coordination is hindered by the insufficient time to use mechanisms, unshared incentives in prescription and, in two networks, the change in the organizational model; 2) professional factors: clinical skills and attitudes towards coordination. CONCLUSIONS: Although doctors perceive that primary and secondary care is coordinated, they also highlighted problems. Identified factors offer valuable insights on where to direct organizational efforts to improve coordination.

Mães Órfãs: cartografia das tensões e resistências ao abrigamento compulsório de bebês em Belo Horizonte / Orphans mothers: cartography of tensions and resistances to the compulsory sheltering of babies in Belo Horizonte

Introdução: A partir de 2014 o abrigamento compulsório dos recém-nascidos de mulheres, na sua maioria negras, usuárias de drogas ou em situação de rua teve aumento expressivo nas maternidades públicas de Belo Horizonte. Essa ação foi coordenada inicialmente por promotores do Ministério Público que usaram como justificativa a afirmação de que determinadas mulheres não são capazes de prestar o cuidado e proteção aos seus filhos, além de colocá-los em situação de risco. Como estratégia elaboraram as recomendações Nº 05 e 06 de 2014 do Ministério Público de Belo Horizonte - MPMG (MINISTÉRIO PÚBLICO 2014a, 2014b) e posteriormente foi publicada a portaria Nº 3 de 2016 pela 23ª Vara Cível da Infância e da Juventude da Comarca de Belo Horizonte - VCIJCBH (TRIBUNAL DE JUSTICA DE MG, 2016). Então como uma forma de resistência e enfrentamento denominou-se "Mães Órfãs" a situação de mulheres que por essas circunstâncias têm perdido seus bebês para a tutela do estado de forma compulsória. (SOUZA et al, 2018, p. 31). Objetivos: Objetivo Geral: Cartografar as tensões e as resistências às normativas do abrigamento compulsório de bebês em Belo Horizonte. Os objetivos específicos são: Identificar e analisar as tensões na construção e implementação das normativas do abrigamento compulsório de bebês em Belo Horizonte; e identificar e analisar as narrativas e estratégias das resistências a estas normativas em Belo Horizonte. Método: Utilizamos uma abordagem qualitativa do tipo interferência, o referencial metodológico da cartografia e trazemos na caixa de ferramenta conceitual o pesquisador in-mundo, o pesquisador militante, a construção conjunta e a multiplicidade das fontes que podem ser utilizadas para obtenção dos dados e que não são dadas a priori. Como parte da produção de dados, nos utilizamos de entrevistas em profundidade com sujeitos envolvidos na elaboração, implementação, institucionalização e resistência às normativas do abrigamento compulsório. Incluímos também os documentos produzidos antes, durante a após as normativas do abrigamento compulsório e utilizamos um diário de campo. Resultados: Encontramos pistas que mostram uma retomada de tendências conservadoras na saúde e na assistência social, o que pode ter facilitado a atuação do judiciário; além disso a presença de concepções higienistas nos serviços de saúde, o contexto de guerra às drogas e o modelo de maternidade sustentado pelo patriarcado foram determinantes no plano macro político. As narrativas construídas para a implantação das normativas passavam pela insuficiência da rede pública para assistir integralmente essas mulheres e seus filhos e o argumento da proteção à criança. Além disso a disputa de modelos de atenção e a articulação de atores com tendências higienistas presentes na rede de saúde e de proteção social atuaram no plano micropolítico para sustentar a proposta das normativas. Como ruídos da implementação das normativas encontramos que ela foi construída e implantada de forma vertical, ou seja, sem a participação social, dos trabalhadores e gestores; houve ainda constrangimento e criminalização dos profissionais dos serviços que não notificaram os casos ou de outra maneira se posicionavam na resistência a essas normativas, havendo também repercussões dentro das instituições de saúde. Encontramos que a portaria esvazia a função da rede SUS. E ainda que algumas mulheres, fugindo das normativas, criaram linhas de desvio, seja indo parir em outra cidade ou até mesmo se esquivando de ser assistida na hora do parto. Outra pista que emergiu neste estudo foram algumas contradições identificadas nos abrigos que recebem esses bebês. Ademais as normativas forjaram uma intensa resistência na cidade que repercutiu nacionalmente e levaram a reestruturação da rede de saúde e proteção social e até à suspensão da portaria.

Introduction: Since 2014, the compulsory sheltering of the newborns of women, mostly black women, drug users or street children, had a significant increase in the public maternities of Belo Horizonte. This action was initially coordinated by public prosecutors who used as justification the statement that certain women are not able to provide care and protection to their children, and put them at risk. As a strategy, recommendations N. 05 and 06 of 2014 were prepared by the Public Prosecutor's Office of Belo Horizonte - MPMG (MINISTÉRIO PÚBLICO, 2014a, 2014b), and subsequently, the Ministerial Order No. 3 of 2016 was published by the 23rd Civil and Child Court of the Comarca de Belo Horizonte - VCIJCBH (MINIS COURT OF JUSTICE OF MG, 2016). Then as a form of resistance and confrontation denominated "Mothers Orphans" the situation of women who by these circumstances have lost their babies to the guardianship of the state of compulsory form. (SOUZA et al, 2018, p.31). Objectives: General Objective: To map the tensions and resistances to the norms of the compulsory shelter of babies in Belo Horizonte. The specific objectives are: To identify and analyze the tensions in the construction and implementation of the norms of the compulsory shelter of babies in Belo Horizonte; and to identify and analyze the narratives and strategies of the resistances to the norms of the compulsory shelter of babies in Belo Horizonte. Methods: We used a qualitative approach of interference, the methodological reference of cartography and we also brought in the conceptual toolbox the in-world researcher, the militant researcher, the joint construction and the multiplicity of the sources that can be used to obtain the data and that are not given a priori. As part of the data production, we used in-depth interviews with subjects involved in the elaboration, implementation, institutionalization and resistance to the norms of compulsory shelter. We also included the documents produced before, during and after the compulsory shelter regulations, and we used a field diary. Results: We found clues that show a resumption of conservative trends in health and social care, which may have facilitated the judiciary; in addition, the presence of hygienist conceptions in health services, the context of war on drugs and the model of motherhood supported by patriarchy were determinant in the macro political plane. The narratives built for the implementation of regulations went through the insufficiency of the public network to fully assist these women and their children and the argument of child protection. In addition, the dispute of attention models and the articulation of actors with hygienist tendencies present in the health and social protection network acted in the micropolitical plan to support the normative proposal. As noises of the implementation of the regulations we find that it was built and implemented vertically, that is, without the social participation of workers and managers; there was also embarrassment and criminalization of service professionals who did not notify the cases or otherwise positioned themselves in resistance to these regulations, and there are also repercussions within the health institutions. We find that the porter empties the function of the SUS network. And yet some women, escaping from regulation, have created escape routes, either going to give birth in another city or even avoiding being assisted at the time of childbirth. Another clue that emerged in this study were some contradictions identified in the shelters that receive these babies. In addition the regulations forged an intense resistance in the city that had national repercussions and led to the restructuring of the health and social protection network and until the suspension of the decree.