Health · IA INSTITUTO

Saúde Responsiva

Between a warning sign and a response, a network needs to be connected.

Saúde Responsiva organises information, communication and follow-up to bring patients, carers, teams and managers closer together. Technology supports care coordination: recognising needs, assigning responsibilities and tracking what happens after each referral.

Explore the programme

Illustration of a doctor and a patient in a connected healthcare setting. — Technology and care serving people.

PROGRAMME OVERVIEW

The person comes first. The network provides care.

From first contact to continued care at home, the proposal integrates assessment of the municipal care network, digital access and follow-up for people with chronic conditions. Each piece of information must reach the team able to act, with records, accountability and response tracking.

3 areas

Monitoring, WhatsApp access and support for chronic condition care.

5 stages

Eligibility, consent, initial assessment, configuration and follow-up.

1 journey

Patient, carer, primary care and hospital connected throughout care.

AREAS OF WORK

Three areas working together.

Monitoring room

A professional structure to track requests, organise information, support care and coordinate responses across the network. Team composition and workflows are defined according to local needs.

WhatsApp access

A digital channel to receive requests, collect initial information and help direct people to services. Appointment requests, reminders and guidance help organise access to primary care.

Follow-up with Next2u

Patient organisation, risk stratification, care history and remote monitoring, with or without a device, according to inclusion criteria and the care plan.

Institutional image of health services and care. — Assessment and implementation are guided by local and team needs.

IN PRACTICE

Understand the situation before implementation.

Health VUCA Prime is the municipal care network assessment stage. It brings together data and indicators to examine health needs, service use, prevention opportunities and primary care response capacity.

Network overview

Analysis of available information on services, care activity, hospital admissions and chronic conditions.

Action priorities

Identification of situations requiring coordination, follow-up or reorganisation of access.

Planning and evaluation

Intervention scenarios and indicators to track clinical, care and management progress.

EXPLORE IN DETAIL

What connects in day-to-day operations.

Explore the areas that make up the programme's approach.

Patients and carers

Registration, guidance, consent and definition of contact channels. Participation considers the person's needs, family context and the team's response capacity.

Primary care and community health workers

Organisation of patients by risk, comorbidity and designated professional. Tasks and visits can be tracked to maintain continuity with the Family Health team.

Alerts and follow-up

Monitoring information helps identify situations needing attention. Alerts guide the team's assessment, with records of actions taken and follow-up of outcomes.

Health record and timeline

A history bringing together relevant information, alerts, care decisions and progress. The timeline makes it easier to understand the patient's journey and maintain continuity between professionals.

Transition after hospital discharge

Care continues after leaving hospital. The proposal provides for organising discharge information, communicating with primary care and following up the actions needed on returning home.

Municipal management

An organised view of demand, risks and the network's responses. Indicators support priority setting, allocation of responsibilities and improvement of care workflows.

INFORMATION THROUGHOUT CARE

A shared history supports continuity of care.

Demonstration screen of a health record and care timeline, with explicitly simulated data. — Platform demonstration from the supplied material: simulated data illustrating health records, alerts and continuity of care. Enlarge image ↗

THE JOURNEY

Monitoring starts with responsible enrolment.

01
Eligibility
Assess clinical and social criteria to determine who may benefit from follow-up.
02
Consent
Explain the purpose, limitations, privacy and how participation works.
03
Initial assessment
Understand the person's baseline condition and care needs.
04
Configuration
Define protocols, responsible professionals, contacts and response channels.
05
Follow-up
Track tasks, alerts and progress, with care plan reviews.

EXPECTED CONTRIBUTIONS

Technology supporting relationships, coordination and continuity.

For people

Better organised access and follow-up connected to the designated care team.

For professionals

Information in one place and clarity about tasks and responsibilities.

For public managers

Better conditions for monitoring the network and guiding decisions.

Remote monitoring supports teams' work. Care decisions remain with the responsible professionals, according to the network's protocols and care conditions.

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