Referenciamento e contrareferenciamento à Atenção Primária de à Saúde de idosos com osteoporose

Abstract

Objective: This study aimed to describe the referral and counter-referral of older adults people with osteoporosis between a secondary care service and primary healthy care service. The study has been developed from two perspectives: 1) from the patient, based on cohort with secondary collecting data and complementary remote survey; 2) from the primary care center manager, based on a telephone survey. A total of 391 patients were included in the study and all of them received a care plan with treatments and measures for prevention of falls and fractures. However, 35.3% were not using osteoporosis medication at the time of the interview. Of the total number of patients, 31.2% had suffered at least one fall in the year prior to the interview and almost half of them reported a fracture. Counter-referral occurred for 89.0% of the patients and, among these, 34.3% had the care plan fully implemented. A total of 140 managers participated in the study and the most part reported that patients have been invited to return to primary heathy care center after receiving the care plan, but just over half affirmed that its implementation is fully feasible. The main reasons for the difficulties are the patient’s lack of social/family support or their social vulnerability and the lack of professionals in the Family Health Support Teams. Social strategies related to family and health care can be useful to ensure the full implementation of care plans for older adults with osteoporosis.