MANEJO MULTIPROFISSIONAL DE PACIENTES COM DOENÇAS CRÔNICAS NO AMBIENTE HOSPITALAR
DOI:
https://doi.org/10.18623/rvd.v23.n3.4662Palabras clave:
Doenças Crônicas, Manejo Multiprofissional, Continuidade do Cuidado, Adesão Terapêutica, Ambiente HospitalarResumen
O manejo de pacientes com doenças crônicas no ambiente hospitalar constitui um desafio crescente para os sistemas de saúde, especialmente diante da complexidade clínica, da multimorbidade e da necessidade de cuidados contínuos. Nesse contexto, o trabalho multiprofissional tem sido apontado como estratégia fundamental para qualificar a assistência e reduzir a fragmentação do cuidado. Assim, o presente estudo tem como objetivo analisar as evidências científicas sobre o manejo multiprofissional de pacientes com doenças crônicas no ambiente hospitalar, com foco nos impactos sobre a continuidade do cuidado, a adesão terapêutica e os desfechos clínicos. Trata-se de uma revisão integrativa da literatura, conduzida de acordo com as recomendações do PRISMA 2020. As buscas foram realizadas nas bases PubMed/MEDLINE, LILACS, SciELO e Web of Science, contemplando estudos publicados entre 2020 e 2026. Os resultados evidenciam que o manejo multiprofissional favorece a coordenação das ações assistenciais, o fortalecimento da continuidade do cuidado e o engajamento do paciente no tratamento, além de contribuir para a qualificação do percurso assistencial e dos desfechos clínicos. Conclui-se que a atuação multiprofissional estruturada no ambiente hospitalar representa uma estratégia essencial para o cuidado de pacientes com doenças crônicas, demandando investimentos institucionais em modelos organizacionais integrados e práticas colaborativas baseadas em evidências.
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AMFORTH, R. J.; CHHIBBA, R.; FERGUSON, T. W.; et al. Strategies to prevent hospital readmission and death in patients with chronic heart failure, chronic obstructive pulmonary disease, and chronic kidney disease: a systematic review and meta-analysis. PLOS ONE, v. 16, n. 4, 2021.
BODENHEIMER, T.; WAGNER, E. H.; GRUMBACH, K. Improving primary care for patients with chronic illness. Journal of the American Medical Association, Chicago, v. 288, n. 14, p. 1775–1779, 2002.
DE GANS, S.; PENTURIJ-KLOKS, M.; SCHEELE, F.; et al. Combined interprofessional and intraprofessional clinical collaboration reduces length of stay and consultations. Journal of Interprofessional Care, v. 37, n. 4, p. 523–531, 2022.
DE VRIES, H. J.; GANSEVOORT, R. T.; BROUWER, S.; et al. Developing and implementing work-oriented clinical care to empower patients with kidney disease: an intervention mapping approach. BMC Health Services Research, v. 23, 2023.
GONÇALVES, I.; MENDES, D. I. A.; CALDEIRA, S.; JESUS, E.; NUNES, E. Nurse-led care management models for patients with multimorbidity in hospital settings: a scoping review. Journal of Nursing Management, v. 30, n. 6, p. 1960–1973, 2022.
GRUDNIEWICZ, A.; STEELE GRAY, C.; BOECKXSTAENS, P.; DE MAESENEER, J.; MOLD, J. W. Operationalizing the chronic care model with goal-oriented care. The Patient: Patient-Centered Outcomes Research, v. 16, p. 569–578, 2023.
HEGGDAL, K.; MENDELSOHN, J. B.; STEPANIAN, N.; OFTEDAL, B. F.; LARSEN, M. H. Health-care professionals’ assessment of a person-centred intervention to empower self-management and health across chronic illness. Health Expectations, v. 24, n. 4, p. 1367–1377, 2021.
JOANNA BRIGGS INSTITUTE. Joanna Briggs Institute Reviewer’s Manual. Adelaide: JBI, 2014.
KELEPOURIS, E.; ST. PETER, W. L.; NEUMILLER, J. J.; WRIGHT, E. E. Optimizing multidisciplinary care of patients with chronic kidney disease and type 2 diabetes mellitus. Diabetes Therapy, v. 14, n. 7, p. 1111–1136, 2023.
LAI, Y. F.; LEE, S.; TAN, Y.-R.; et al. One-bed-one-team: does an integrated general hospital inpatient model improve care outcomes and productivity? Frontiers in Public Health, v. 10, 2022.
LJUNGHOLM, L.; EDIN-LILJEGREN, A.; EKSTEDT, M.; KLINGA, C. What is needed for continuity of care and how can we achieve it? Perceptions among multiprofessionals on the chronic care trajectory. BMC Health Services Research, v. 22, n. 1, 2022.
LJUNGHOLM, L.; KLINGA, C.; EDIN-LILJEGREN, A.; EKSTEDT, M. What matters in care continuity on the chronic care trajectory for patients and family carers? A conceptual model. Journal of Clinical Nursing, 2021.
MARTIN, A. K.; GREEN, T.; MCCARTHY, A. L.; SOWA, P. M.; LAAKSO, E.-L. Allied health transdisciplinary models of care in hospital settings: a scoping review. Journal of Interprofessional Care, v. 37, n. 1, p. 118–130, 2022.
MAS, M. À.; MIRALLES, R.; HERAS, C.; et al. Designing a person-centred integrated care programme for people with complex chronic conditions: a case study from Catalonia. International Journal of Integrated Care, v. 21, n. 4, p. 22, 2021.
MATTINA, A.; ARGANO, C.; BRUNORI, G.; et al. Clinical complexity and diabetes: a multidimensional approach for the management of cardiorenal metabolic syndrome. Nutrition, Metabolism and Cardiovascular Diseases, v. 32, n. 12, p. 2730–2738, 2022.
MURTAGH, S.; MCCOMBE, G.; BROUGHAN, J.; et al. Integrating primary and secondary care to enhance chronic disease management: a scoping review. International Journal of Integrated Care, v. 21, n. 1, p. 4, 2021.
ORGANIZAÇÃO MUNDIAL DA SAÚDE. Global report on diabetes. Geneva: World Health Organization, 2020.
PAGE, M. J.; et al. The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. BMJ, London, v. 372, n. 71, p. 1–9, 2021.
PANY, M. J.; CHEN, L.; SHERIDAN, B.; HUCKMAN, R. S. Provider teams outperform solo providers in managing chronic diseases and could improve the value of care. Health Affairs, v. 40, n. 3, p. 435–444, 2021.
PIÑEIRO-FERNÁNDEZ, J. C.; FERNÁNDEZ-RIAL, Á.; SUÁREZ-GIL, R.; et al. Evaluation of a patient-centered integrated care program for individuals with frequent hospital readmissions and multimorbidity. Internal and Emergency Medicine, 2021.
RAHAYU, S. A.; WIDIANTO, S.; DEFI, I. R.; ABDULAH, R.; ABDULAH, R. Role of pharmacists in the interprofessional care team for patients with chronic diseases. Journal of Multidisciplinary Healthcare, v. 14, p. 1701–1710, 2021.
SIBBALD, S. L.; MISRA, V.; DASILVA, M.; LICSKAI, C. A framework to support the progressive implementation of integrated team-based care for the management of COPD: a collective case study. BMC Health Services Research, v. 22, n. 1, 2022.
SIBBALD, S. L.; ZIEGLER, B. R.; MASKELL, R.; SCHOUTEN, K. Implementation of interprofessional team-based care: a cross-case analysis. Journal of Interprofessional Care, v. 35, n. 5, p. 654–661, 2021.
SREEPATHY, P.; KIM, Y. J.; AHUJA, Z.; SHROFF, A.; NAZIR, N. T. The association between implementation of multidisciplinary rounds and clinical outcomes. Frontiers in Cardiovascular Medicine, v. 9, 2022.
TOMASCHEK, R.; LAMPART, P.; SCHEELE-SAILER, A.; et al. Improvement strategies for the challenging collaboration of general practitioners and specialists for patients with complex chronic conditions: a scoping review. International Journal of Integrated Care, v. 22, n. 3, p. 4, 2022.
WAGNER, E. H.; AUSTIN, B. T.; DAVIS, C.; HINDMARSH, M.; SCHAEBERLE, J.; BORMAN, L. Improving chronic illness care: translating evidence into action. Health Affairs, Millwood, v. 20, n. 6, p. 64–78, 2001.
WHITTEMORE, R.; KNAFL, K. The integrative review: updated methodology. Journal of Advanced Nursing, v. 52, n. 5, p. 546–553, 2005.
WINKELMANN, J. How can skill-mix innovations support the implementation of integrated care for people with chronic conditions and multimorbidity? International Journal of Integrated Care, 2023.
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