[Matrixing support as an instrument of primary healthcare in mental health: multiple views and devices for resolution]

Matrix support in Mental Health: narrative revision of the concepts horizontality and supervision and their practical implications

The Matrix Support (MS) is one of the cornerstones of the integration between Primary Health Care (PHC) professionals and Mental Health professionals (MH). A narrative review was conducted on the articles on MS in MH published in national databases from 1998 to 2017, considering a brief history of the PHC reorganization processes that led to the creation of the MS proposal. The aim was to understand the meanings attributed to the terms "horizontality" and "supervision" as well as the descriptions of the "matrix support" itself. We sought to identify factors contributing to the difficulties that have been described in the practices and literature, based on the assumption that these concepts are polysemous and it is possible to generate ambiguities that operate to the detriment of interprofessional practices. Based on the analysis of the selected articles, we were able to conclude that, in addition to polysemy, the obstacles' force lies in the hegemonic model of professional Health training, as it is traditional, hierarchical and uni-professional, and hinders the development of dialogic relations that favor the integration of the matrix support teams and PHC and consequent resolubility and quality of care.

Mental Health Studies published in the last 25 years in the Journal Ciência & Saúde Coletiva

A systematic review of the 25-year Mental Health production of Journal Ciência & Saúde Coletiva was performed to identify whether this production had changed over time. We investigated whether these changes would have any relationship with the implementation of a new regulatory and legal framework for this field and the expansion of public services and the promotion of public funding agencies' investigation on the subject. A total of 278 original papers were analyzed from the following categories: sociocultural transformations related to madness and its approach; legislative changes; implantation, coverage range and operation of the network of substitute services; clinic/care developed in substitute services; the role and possibilities of primary care; drug use-related problems; mental health of children and adolescents; epidemiological studies/psychiatric categories; and others - which included ethnic-racial issues, violence, about the elderly population, suicide, bullying, and migration. A chronological relationship can be observed between the increase in publications and research notices and the expansion of services, not seemingly in the same way concerning care for people with alcohol and other drug problems.

APOIO MATRICIAL COMO ESTRATÉGIA DE ORDENAÇÃO DO CUIDADO EM SAÚDE MENTAL

Resumo O estudo do tipo qualitativo e transversal, com o objetivo de analisar a perspectiva dos profissionais dos centros de atenção psicossocial acerca do apoio matricial como estratégia de cuidado psicossocial em saúde mental. Foram utilizadas dez entrevistas semiestruturadas com profissionais de serviços de saúde mental do município de Imperatriz, Maranhão. Depreendeu-se que esses profissionais compreendem o apoio matricial como ferramenta indispensável para a organização do cuidado psicossocial, mas este ainda é utilizado de modo incipiente no seu cotidiano de trabalho ante os desafios relativos à: coexistência do modelo psicossocial com o biomédico; falta de condições de trabalho; falta de educação continuada e permanente da rede de atenção; burocratização e verticalização das ações da gestão; e motivação para o trabalho entre as equipes. Algumas vivências exitosas de apoio matricial para esses trabalhadores resultaram da cogestão dos processos de trabalho entre profissionais e usuários. Recomenda-se que haja um claro direcionamento do trabalho por parte da gestão, com a definição de uma equipe de matriciadores e um planejamento para sua realização, construindo processos de trabalho que favoreçam tal prática.

Mental health in primary care: experience of matrix strategy in the rural area

ABSTRACT Objective: to report the development of Mental Health actions shared between the Family Health Strategy located in a rural area and the Matrix Support Team by showing the communication resulting from this singular configuration. Method: report of experience about the implementation of actions of the Family Health Support Center (Portuguese acronym: NASF) in mental health care for a rural population. Results: the following health needs were identified: psychoactive drugs consumption, lack of activities for collective care and difficulty with access to service. The expansion of actions and intersectoral involvement of actors were demonstrated as the educational attitudes were implemented. Final considerations: the articulation between family health workers, matrix support and community was key for the implementation of mental health care aligned with the psychosocial approach.

Apoio matricial como estratégia para o fortalecimento da saúde do trabalhador na atenção básica

Resumo Introdução: a garantia da atenção integral à saúde do trabalhador requer a incorporação sistemática de ações na atenção básica, sendo o apoio matricial uma estratégia potente para sua viabilização. Objetivo: descrever e analisar as práticas de apoio matricial desenvolvidas por um Centro de Referência em Saúde do Trabalhador (Cerest) junto à rede de serviços de atenção básica, com vistas à incorporação de ações de saúde do trabalhador. Métodos: estudo de natureza descritiva. Realizou-se entrevista semiestruturada com 41 profissionais que participaram do processo de matriciamento. Os dados foram analisados segundo a técnica de análise de conteúdo. Resultados: o apoio matricial possibilitou a ampliação de práticas que reconhecem o usuário enquanto trabalhador e o trabalho como determinante do processo saúde-doença. Com o aumento da resolutividade dos casos e maior articulação entre os profissionais do Cerest e da rede de atenção básica, houve redução dos encaminhamentos aos Cerest. Os desafios identificados incluem a necessidade de qualificar apoiadores e o enfrentamento da sobrecarga de trabalho e da ênfase nas ações assistenciais que ocorrem em detrimento das de vigilância, dificultando a integralidade do cuidado. Conclusão: o apoio matricial pode operar como estratégia potente de fortalecimento da saúde do trabalhador no Sistema Único de Saúde (SUS).

Mental health in Primary Care: challenges for the resoluteness of actions

ABSTRACT Objective: To identify the challenges faced by professionals to add resoluteness to actions in mental health developed in the context of Primary Care. Method: Qualitative study with 30 professionals, including 17 nurses, four doctors, five psychologists and four social workers. Data were collected in three municipalities of Rio Grande do Sul, Brazil, in April 2018, through a semi-structured interview, later submitted to thematic analysis. Results: Challenges pointed out by professionals to add resoluteness to actions in mental health are related to the lack of specific knowledge to support the actions professionals perform; with the organization of services and participation of managers; and with the ambivalence of people with mental disorders regarding acceptance and continuity of treatment. Conclusion: The construction of shared practices among professionals, people with mental disorders and their families is necessary. Implications for practice: The study allows theoretical-practical articulations capable of generating transformations in mental health care model.

NÚCLEO DE APOIO À SAÚDE DA FAMÍLIA E TRABALHO INTERPROFISSIONAL: A EXPERIÊNCIA DO MUNICÍPIO DE CAMPINAS (SP)

Resumo Este estudo buscou compreender a dinâmica do processo de institucionalização do único Núcleo de Apoio à Saúde da Família implantado em Campinas, São Paulo. Embora seja município precursor da prática de apoio matricial, nele a implantação do Núcleo ocorre em ritmo lento, sendo relevante identificar fatores relacionados à inexpressiva presença deste arranjo organizacional, assim como analisar suas práticas. Optou-se pelo emprego do estudo de caso único, e para a produção de material empírico utilizou-se a observação participante e grupos focais. Os dados foram agrupados em dois eixos: a ‘história feita’, focalizando o contexto das políticas de saúde municipais; a ‘história se fazendo’, que remete à compreensão das percepções dos participantes daquela história. Observou-se que a experiência do Núcleo de Apoio à Saúde da Família estudado apresenta potencialidades e tensões. A metodologia do apoio matricial fundamenta a atuação da equipe e favorece o vínculo com a atenção básica, o desenvolvimento de uma relação interprofissional interativa, pautada no intercâmbio de conhecimentos e fortalecimento do trabalho em rede. Entretanto, as dificuldades para a ampliação desses núcleos como arranjo organizacional prioritário indicam a permanência de tensões que remetem ao histórico de conformação das práticas de matriciamento, pautadas em equipes autônomas e organizadas por áreas temáticas.

Centro de Atenção Psicossocial (CAPS): ações desenvolvidas em município de Minas Gerais, Brasil

Esta pesquisa teve como objetivo apresentar as ações desenvolvidas em Centro de Atenção Psicossocial [CAPS, modalidade II], no ano de 2015, em município de Minas Gerais. Trata-se de um estudo retrospectivo, descritivo exploratório, com base em fonte de dados secundários consultados no Tabulador para Windows [TABWIN]. Com isso, foi constatado que é possível o CAPS desenvolver ações intersetoriais, multidisciplinares, de promoção e prevenção de agravos para a saúde mental, além de atenção à crise. Dessa forma, é importante estudos que apresentem discussões em torno do fortalecimento do protagonismo de usuários assistidos na esfera da saúde mental e a garantia de espaços participativos em toda a sociedade.

Mindfulness as a complementary intervention in the treatment of overweight and obesity in primary health care: study protocol for a randomised controlled trial

Background

Mindfulness has been applied in the United States and Europe to improve physical and psychological health; however, little is known about its feasibility and efficacy in a Brazilian population. Mindfulness may also be relevant in tackling obesity and eating disorders by decreasing binge eating episodes—partly responsible for weight regain for a large number of people—and increasing awareness of emotional and other triggers for overeating. The aim of the present study protocol is to evaluate and compare the feasibility and efficacy of two mindfulness-based interventions (MBIs) addressing overweight and obesity in primary care patients: a general programme called Mindfulness-Based Health Promotion and a targeted mindful eating protocol called Mindfulness-Based Eating Awareness Training.

Methods/design

A randomised controlled trial will be conducted to compare treatment as usual separately in primary care with both programmes (health promotion and mindful eating) added to treatment as usual. Two hundred forty adult women with overweight and obesity will be enrolled. The primary outcome will be an assessment of improvement in eating behaviour. Secondary outcomes will be (1) biochemical control; (2) anthropometric parameters, body composition, dietary intake and basal metabolism; and (3) levels of mindfulness, stress, depression, self-compassion and anxiety. At the end of each intervention, a focus group will be held to assess the programme’s impact on the participants’ lives, diet and health. A feasibility study on access to benefits from and importance of MBIs at primary care facilities will be conducted among primary care health care professionals and participants. Monthly maintenance sessions lasting at least 1 hour will be offered, according to each protocol, during the 3-month follow-up periods.

Discussion

This clinical trial will result in more effective mindfulness-based interventions as a complementary treatment in primary care for people with overweight and obesity. If the findings of this study confirm the effectiveness of mindfulness programmes in this population, it will be possible to improve quality of life and health while optimising public resources and reaching a greater number of people. In addition, on the basis of the evaluation of the feasibility of implementing this intervention in primary care facilities, we expect to be able to suggest the intervention for incorporation into public policy.

Trial registration

ClinicalTrials.gov, NCT02893150. Registered retrospectively on 30 March 2017.

Electronic supplementary material

The online version of this article (10.1186/s13063-018-2639-y) contains supplementary material, which is available to authorized users.

Matrix support strategies: the experience of two Family Health Support Centers (NASFs) in São Paulo, Brazil

The aim of Family Health Support Centers (NASFs) is to expand and qualify primary health care initiatives. Working together with Family Health Teams (EqSFs) they use matrix support strategies. This paper discusses how NASF professionals develop their work, emphasizing how matrix support approaches are appropriated and incorporated into daily working practices. The results that are presented are based on a case study of the work process of NASFs in a region of the city of São Paulo, Brazil. In order to investigate this issue, specific questions were introduced at different stages of the ergonomic work analysis. The implementation of the NASF, without a review of the guidance documents provided by the EqSF, created the following paradoxes: the different requirements of productivity and the working strategies between the NASF and the EqSF; the different demands of care for the population and different priorities for action, which were reflected in the division of tasks and the time allocated to each of them, etc. The practices that have been accumulated since the creation of the NASF suggests a review of these documents in order to transform the organization of planned work of these organizations in order to create better conditions for shared working practices.

Atenção especializada ambulatorial no Sistema Único de Saúde: para superar um vazio

Resumo A estruturação da atenção especializada ambulatorial é um gargalo na construção do Sistema Único de Saúde. A partir de breve discussão desse vazio de um modelo organizativo, propomos a indução federal de um formato de serviços especializados a partir das experiências dos Núcleos de Apoio à Saúde da Família (NASF), cuja atuação matricial adaptada é um protótipo ótimo de organização do cuidado especializado ambulatorial. Ela permite a equidade no acesso e a máxima proximidade do cuidado especializado da realidade dos usuários, o relacionamento personalizado e a articulação íntima entre as equipes de saúde da família e os especialistas, viabilizando educação permanente mútua, regulação negociada e aumento da resolubilidade da atenção básica. Aspectos das experiências municipais de Florianópolis e Curitiba são sintetizadas como exemplos parciais da proposta. É brevemente descrita a estruturação do cuidado em saúde mental de Florianópolis, toda organizada como apoio matricial; e a mudança de enfoque das equipes de apoio de Curitiba, que progressivamente passaram a sem empenhar, envolver e mediar a relação entre a atenção básica e a especializada. Este formato pode ser adaptado e expandido para a maioria das especialidades médicas.

O "cabo de força" da assistência: concepção e prática de psicólogos sobre o Apoio Matricial no Núcleo de Apoio à Saúde da Família

O presente estudo analisou a concepção e a prática do matriciamento realizadas por psicólogos que trabalham no Núcleo de Apoio à Saúde da Família (NASF) no Município de São Paulo, Brasil. Foi utilizada a metodologia qualitativa, foram realizadas entrevistas semiestruturadas, gravadas e transcritas, submetidas à análise de conteúdo do tipo temática. Essa pesquisa demonstra dilemas entre a prescrição do trabalho e o que é possível ser realizado na prática, e entre a idealização da proposta colaborativa e sua implantação. A troca de saberes e a capacitação apareceram como principais significados da concepção de matriciamento. A prática revelou um contexto complexo com uma organização de trabalho bastante heterogênea com falta de articulação entre gerências e tensões na execução do trabalho compartilhado, como a divisão desigual de tarefas, em que as equipes de saúde da família devem se responsabilizar pela assistência direta à população enquanto o NASF ocupa o lugar daquele que capacita e supervisiona, gerando conflitos sobre de quem é a responsabilidade da assistência, constituindo um contexto pouco propício ao cuidado integral, compartilhado e colaborativo.

Implementation of 'matrix support' (collaborative care) to reduce asthma and COPD referrals and improve primary care management in Brazil: a pilot observational study

Asthma and chronic obstructive pulmonary disease (COPD) are leading causes of hospitalisation and death in the city of Sao Bernardo do Campo. The municipality had difficulties in sustaining a pulmonology specialist team. Local policy has strengthened the knowledge of the primary care teams to improve the management of these diseases. Our aim is to pilot the implementation of an educational intervention based on collaborative care focused on reducing respiratory-related referrals. We implemented 'matrix support': a Brazilian collaborative educational intervention promoting specialist training and support for primary care physicians in three health territories with the highest number of referrals. Clinicians and nurses from primary care attended an 8-h workshop. The backlog of respiratory referrals was prioritised, where Asthma and COPD represented 70% of referral reasons. Initially, pulmonologists held joint consultations with physicians and nurses; as confidence grew, these were replaced by round-table note-based case discussions. The primary outcome was the number of asthma and COPD referrals. Almost all primary healthcare professionals in the three areas (132 of 157-87%) were trained; 360 patients were discussed, including 220 joint consultations. The number of respiratory referrals dropped from 290 (the year before matrix support) to 134 (the year after) (P<0.05). Referrals for asthma/COPD decreased from 13.4 to 5.4 cases per month (P=0.09) and for other lung diseases from 10.8 to 5.3 cases per month (P<0.05). Knowledge scores showed a significant improvement (P<0.001). Matrix-support collaborative care was well-accepted by primary care professionals associated with improved knowledge and reduced respiratory referrals. The initiative attracted specialists to the region overcoming historical recruitment problems.

Apoio Matricial no SUS Campinas: análise da consolidação de uma prática interprofissional na rede de saúde

Resumo Este estudo teve por objetivo caracterizar as equipes e o processo de trabalho interprofissional do Apoio Matricial desenvolvido na Atenção Básica do SUS de Campinas (SP). Para isso, foi realizado estudo exploratório descritivo, com aplicação de questionário a 232 profissionais que realizam Apoio Matricial à Atenção Básica. Para a análise, os dados foram agrupados em quatro categorias: Identificação dos profissionais; Vinculação de trabalho ao SUS Campinas; Organização do trabalho do apoiador matricial; Práxis do apoio. O estudo apontou que a metodologia do Apoio para o trabalho interprofissional logrou importante grau de consolidação no município, apesar do restrito investimento. A reduzida carga horária dedicada ao Apoio e o elevado número de equipes apoiadas para cada equipe de Apoio Matricial foram identificados como as principais fragilidades no processo de trabalho. Por sua vez, emergiram como pontos fortes a multiplicidade de ferramentas utilizadas, a possibilidade de construção compartilhada das diretrizes de trabalho e a flexibilidade na composição das equipes de Apoio. Tanto as fragilidades quanto as potencialidades encontradas podem oferecer subsídios para a reflexão e a concretização do Apoio Matricial em outras realidades.

The matrix approach to mental health care: Experiences in Florianopolis, Brazil

This article reports on the experience of a matrix approach to mental health in primary health care. Professionals who work in the Family Health Support Nuclei, Núcleos de Apoio à Saúde da Família, pointed to challenges of this approach, especially regarding the difficulties of introducing pedagogic actions in the health field and problems related to work relationships. As the matrix approach and its practice are new aspects of the Brazilian Unified Health System, the academic knowledge must walk hand in hand with everyday professional practice to help improve the quality of the services offered in this context.

Barriers to healthcare coordination in market-based and decentralized public health systems: a qualitative study in healthcare networks of Colombia and Brazil

Although integrated healthcare networks (IHNs) are promoted in Latin America in response to health system fragmentation, few analyses on the coordination of care across levels in these networks have been conducted in the region. The aim is to analyse the existence of healthcare coordination across levels of care and the factors influencing it from the health personnel' perspective in healthcare networks of two countries with different health systems: Colombia, with a social security system based on managed competition and Brazil, with a decentralized national health system. A qualitative, exploratory and descriptive-interpretative study was conducted, based on a case study of healthcare networks in four municipalities. Individual semi-structured interviews were conducted with a three stage theoretical sample of (a) health (112) and administrative (66) professionals of different care levels, and (b) managers of providers (42) and insurers (14). A thematic content analysis was conducted, segmented by cases, informant groups and themes. The results reveal poor clinical information transfer between healthcare levels in all networks analysed, with added deficiencies in Brazil in the coordination of access and clinical management. The obstacles to care coordination are related to the organization of both the health system and the healthcare networks. In the health system, there is the existence of economic incentives to compete (exacerbated in Brazil by partisan political interests), the fragmentation and instability of networks in Colombia and weak planning and evaluation in Brazil. In the healthcare networks, there are inadequate working conditions (temporary and/or part-time contracts) which hinder the use of coordination mechanisms, and inadequate professional training for implementing a healthcare model in which primary care should act as coordinator in patient care. Reforms are needed in these health systems and networks in order to modify incentives, strengthen the state planning and supervision functions and improve professional working conditions and skills.

Evaluating the effectiveness of care integration strategies in different healthcare systems in Latin America: the EQUITY-LA II quasi-experimental study protocol

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 country's 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.

Do existing mechanisms contribute to improvements in care coordination across levels of care in health services networks? Opinions of the health personnel in Colombia and Brazil

BACKGROUND

The fragmentation of healthcare provision has given rise to a wide range of interventions within organizations to improve coordination across levels of care, primarily in high income countries but also in some middle and low-income countries. The aim is to analyze the use of coordination mechanisms in healthcare networks and its implications for the delivery of health care. This is studied from the perspective of health personnel in two countries with different health systems, Colombia and Brazil.

METHODS

A qualitative, exploratory and descriptive-interpretative study was conducted, based on a case study of healthcare networks in two municipalities in each country. Individual semi-structured interviews were conducted with a three stage theoretical sample of a) health (112) and administrative (66) professionals of different care levels, and b) managers of providers (42) and insurers (14). A thematic content analysis was conducted, segmented by cases, informant groups and themes.

RESULTS

The results show that care coordination mechanisms are poorly implemented in general. However, the results are marginally better in certain segments of the Colombian networks analyzed (ambulatory centres with primary and secondary care co-location owned by or tied to the contributory scheme insurers, and public providers of the subsidized scheme); and in the network of the state capital in Brazil. Professionals point to numerous problems in the use of existing mechanisms, such as the insufficient recording of information in referral forms, low frequency and level of participation in shared clinical sessions, low adherence to the few available clinical guidelines and the lack of or inadequate referral of patients by the patient referral centres, particularly in the Brazilian networks. The absence or limited use of care coordination mechanisms leads, according to informants, to the inadequate follow-up of patients, interruptions in care and duplication of tests. Professionals use informal strategies to try to overcome these limitations.

CONCLUSIONS

The results indicate not only the limited implementation of mechanisms for coordination across care levels, but also a limited use of existing mechanisms in the healthcare networks analyzed. This has a negative impact on coordination, efficiency and quality of care. Organizational changes are required in the networks and healthcare systems to address these problems.

[Solvability of mental health care in the Family Health Strategy: social representation of professionals and users]

OBJECTIVE

To aprehend the social representations about the solvability in mental health care with users of the Family Health Strategy and professionals of family health teams and of the Center for Psychosocial Care.

METHOD

A qualitative study using semi-structured interviews for data collection, and the Alceste software for analysis. This software uses the Hierarchical Descending Classification based on the examination of lexical roots, considering the words as units and providing context in the corpus.

RESULTS

The representations emerge in two opposing poles: the users require satisfaction with care and the professionals realize the need for improvement of health actions. Although the matricial support in mental health and the home visits are developed, the barriers related to investment in health, continuing education and organization of care persist.

CONCLUSION

The different representations enable improvements in customer service, solvability of care and aggregate knowledge and practices in the expanded perspective of health needs in the family, social and therapeutic context.


Matrix support, individual therapeutic project and prodution in mental health care

The study aimed to understand how to conform the Support Matrix and Individual Therapeutic Project and its relation with the production of mental health care. This is qualitative research conducted in Fortaleza-CE, Center for Psychosocial Care and Center for Family Health. 17 people participated, between professionals and patients. It was used as for dates collecting semi-structured and systematic observation. The findings were analyzed by narrative analysis, grounded theory by Ricoeur. The results reveal themselves excessive referrals, medical-centered, dependence Health Center to support the specialized care, deficiency of physical space, network disconnection, outsourcing and professional unpreparedness of the Health Center as the production difficulties of care. The Support Matrix and Individual Therapeutic Project therefore happen in everyday services, but with difficulties that affect the organization and production of care.

"Fui lá no posto e o doutor me mandou foi pra cá": processo de medicamentalização e (des)caminhos para o cuidado em saúde mental na Atenção Primária

Buscou-se compreender como o cuidado em saúde mental vem sendo produzido na Atenção Primária, com base nas experiências de profissionais, usuários e familiares. As informações obtidas foram categorizadas pelos aspectos observados na efetivação da interface entre Atenção Primária e saúde mental, descritos como: medicamentalização dos problemas de saúde mental apresentados pela população; dificuldades no acesso dos usuários do Centro de Atenção Psicossocial (CAPS) à Unidade de Saúde da Família, e formação em saúde mental para os profissionais da Atenção Primária. O processo de medicamentalização perpassa as práticas dos profissionais e configura-se como a principal demanda dos usuários do CAPS, indicando a necessidade de ações desmedicalizantes, que encontram potência na incorporação de novas relações e dinâmicas sociais no território, maior articulação das equipes e estímulo à participação social da comunidade neste processo.