Do monitoramento à intervenção: avaliação do risco cardiovascular em pacientes domiciliares com hipertensão e diabetes

Abstract

This work is an intervention project developed within the Marruás Family Health Strategy (FHS), located in the municipality of Tauá, State of Ceará, focusing on the follow-up of bedridden and homebound patients with systemic arterial hypertension (SAH) and/or type 2 diabetes mellitus (T2DM). Considering the high burden of morbidity and mortality associated with these chronic conditions—especially when they coexist in the same individual—the project aims to stratify cardiovascular risk and implement comprehensive care measures. The methodology includes the active identification of patients using data provided by the family health team and community health workers, home visits for blood pressure measurement and glycated hemoglobin testing, application of clinical risk- stratification protocols, and implementation of interventions according to the vulnerabilities identified, including therapeutic adjustment, health education, and regular follow-up. The expected results include improved clinical control parameters, reduction of preventable complications, expanded coverage of actions that contribute to the Previne Brasil program indicators, and strengthened care coordination in Primary Health Care. The project also aims to contribute to the qualification of the team’s care practices and to the promotion of health among users in situations of greater vulnerability.