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Development of a care guide for people with hypertension and type 2 diabetes for interprofessional primary health care teams

Carmen CARVALHO, António Bartolomeu JÁCOMO, Maria Teresa SILVA and Miguel VIEIRA

The demographic transition in many countries is highlighted by the accelerated aging of the population and the high prevalence of hypertension and type 2 diabetes mellitus (DM2). It is necessary that the care be guided by the Chronic Conditions Model (CCM), characterized by: vulnerability and cardiovascular risk stratification, comprehensive care by an interprofessional team, person-centered approach, evidence-based practices, supported self-care, and a monitoring and evaluation system.The Interprofessional Working Group for the Care of People with Chronic Conditions of the XXX developed the Hypertension and DM2 Care Guide to support decision-making in Primary Health Care (PHC), improve care, and subsidize a continuing education process to promote the CCM. The content was defined based on updated guidelines and reviewed by PHC specialists. The guide was organized using an objective layout, based on diagrams, flowcharts, and mind maps for rapid clinical decision-making. It consists of six sections: CCM – Pillars of care in hypertension and DM2; Technologies and Support Tools (e.g., Motivational Interviewing); Lifestyle Changes; Care for People with Type 2 Diabetes; Care for People with Hypertension.The Guide adapts the latest evidences to the reality and public health resources of the local population.The Guide enhances the practical learning and can be used for quick reference by PHC professionals during their clinical practice and for the development of continuing education programs for these same professionals. It can be adapted to other health systems according to their organizational structure of professionals and available resources.Facing the overload of PHC with acute demands, high staff turnover and a focus on productivity, consolidating the CCM and the good care practices represents a political and educational challenge. The Guide and the continuing educations developed from it emerge as strategies capable of promoting effective and sustainable improvements in the daily routine of PHC.Implementation of the Guide, integrated with continuing education, encourages the adoption of evidence-based practices, the consolidation of the CCM, and fosters the protagonism of PHC teams. The Guide stands out as a relevant and strategic tool to improve the quality of health care for people with hypertension and DM2 in PHC.