EVALUATION OF THE COORDINATION OF CARE BY USERS OF PRIMARY HEALTH CARE SERVICES

Introduction: the coordination of care is shown as a strategic point of interventions in primary health care (PHC). Objective: to evaluate the quality of PHC services in a regional health coordination through users in the dimension of coordination of care. Method: analytical, cross-sectional study, in which 1,071 adult users from 32 municipalities that make up two health regions were interviewed. The primary care assessment tool (Primary Care Assessment Tool) Brazil was used in the adult version, and Pearson and Kruskal-Wallis chi-square tests were performed. Results: there was a high score in the dimension “integration of care” in the basic health unit (BHU) (6.66), Family Health Strategy (FHS) (6.34) and integrated BHU (6.87) and high score in the dimension “information systems” at BHU (7.22), FHS (7.09) and integrated BHU (7.27), with no significant differences in the assessment between the different models of care. The dimension of coordination of care, in the present study, was well evaluated, obtaining a high score in the different models of care. In addition, the study indicated that there was no statistical difference between them in PHC, as assessed by users. Conclusion: the study contributes so that PHC can be rethought in relation to the model that is being implemented in units with FHS, whose results need to be reflected by municipal and regional health managers.


INTRODUCTION
Health assessment is related to quality control, since, when assessing, the services offered are continuously monitored, in order to identify and correct weaknesses found early, providing the improvement and development of the services evaluated. Evaluation is understood as a formal intervention that requires resources and actors committed to improving decisions. 1 In the same way, the evaluation of health programs and services aims to improve their execution, as far as it increases their effectiveness and efficiency by providing useful information for a better distribution of infrastructure and available resources. Added to the assistance in conducting the cycle of planning, development, implementation and operationalization of future programs. 1,2 The coordination of care is shown to be a strategic point of intervention. It is understood as a set of actions aimed at the continuity of care, with the perspective of the articulation of health services, in order to compose a synchronized intervention and with the common objective of integrating and rationalizing the system and the use of information about individual and collective care, over time and in different spaces, subsidizing decisions and planning. 2,3 The search for a new care model centered on Primary Health Care (PHC) stems from a historical social moment, in which the technicist, hospital-centered model no longer meets the emergence of changes in the modern world and, consequently, the health needs of users. In this sense, the Family Health Strategy (FHS) presents itself as a model of care for health services, with the family at the center of attention, incorporating a new look in the intervention process and seeking to implement preventive actions. 4 PHC is the first level of assistance in the system and its essential attributes are the individual's first contact with the health system, continuity and integrality of care and coordination of care within the system. In addition to three other derived attributes: family and community orientation and cultural competence. 2 Based on this, there is a friendly, resolute PHC perspective that advances in the management and coordination of user care in the health care network (HCN). 4 In this context, the coordination of care has the capacity to guarantee continuity of care in the different points of the HCN and its essence is the availability of information about previous problems and services and the recognition of these to meet current needs. Without coordination, longitudinality would decrease its potential, integrality would be compromised and the attribution of first contact would have an essentially administrative connotation . 2,5 The evaluation must be implemented in a transversal way in the health actions in the PHC, being understood as a management and care process developed by the multiprofessional team, in a shared way, whose objective is to improve and adapt directions and conduct. Evaluation has a management and support tool for the consolidation of the Unified Health System (Sistema Único de Saúde, SUS), as it strengthens or develops the technical qualification of managers, health workers and users in the adoption of monitoring and evaluation actions relevant to planning and management, in addition to subsidize the formulation of policies and assist in the decision-making and training process of the actors involved. 3 Thus, the research was conducted with the following question: "how is the degree of coordination of care in the PHC network evaluated by users in a regional health coordinator in Rio Grande do Sul?" Therefore, it aimed to assess the quality of services of primary health care in a regional health coordination through users in the dimension of coordination of care.
"certainly yes" (value=4), "probably yes" (value=3), "probably not" (value=2), "certainly not" (value =1) and "I don't know/ don't remember" (value=9). After consolidating the data related to the attention coordination attribute, the values were transformed into a continuous scale, varying between zero and 10, using the following formula: Ep=[(score obtained-1)x10]/3. Ep≥6.6 were defined as high and equivalent to the value three or more (≥3) on the Likert scale, while Ep ≤6.6 was considered low. 8 Pearson's chi-square test was performed to assess the associations between the attention coordination attribute and the users' characteristics. The tests assumed a 5% significance level and a 95% confidence interval.

RESULTS
The analysis of the research data was made from the perspective of the health care model that composes the 4 th RHC/RS. One thousand and seventy-one interviews were carried out with adult users from the 32 municipalities in the 4th RHC/RS. The sociodemographic characteristics of these users are shown in Table 1.
It was found that there is an association between the conventional BHU, FHS and integrated BHU care models in the health regions of Verdes Campos and Entre Rios. The same is true for age, training, race, transportation, employment and income. As for sex, marital status, health plan and number of children, the variables are independent, that is, distinct, in relation to the type of unit.
In the attribute of coordination of care, integration of care and information system, the analysis showed that there is no significant difference between BHU, FHS and integrated BHU in the evaluation of users. In the consultation with a specialist, 44.78% of the BHU users have already received assistance in a specialized service, 49. 11% of the FHS and 52.94% of the integrated BHU. In addition, when assessing the average of the coordination scores that is composed of the integration of care and information system, considering the maximum and minimum limits, the score was high in the different service models (Table 2). two health regions called Verdes Campos, composed of 21 municipalities, and Entre Rios, composed of 11 municipalities. The PHC model in these regions has a conventional basic health unit (BHU), FHS and integrated BHU.
PHC is organized based on two models of care, BHU with or without Community Health Agents (CHA) and the FHS. Both are fixed structures located close to the user's home, in geographically delimited areas. Although the BHU are a reference for an enrolled population of 15 to 20 thousand inhabitants, they are not as close as the FHS units, which cover smaller population contingents. 6 There is also the integrated BHU, where health services can be observed with the performance of an FHS team and a team of the conventional model or specialist professionals, configuring an integrated care model.
Research subjects were adults aged 18 years or older, whose access to the health service was not the first. The sampling was probabilistic, not random and for convenience, with the sample delimited by a sample calculation based on an estimate of the population average, considering the following parameters for the sampling of adult users: population estimate for the year 2014 equal to 559,498 and adults of 406,741 with normal distribution 1.96, p=0.5, e=0.3 and α=0.05.
The sample of adult users consisted of 1,071 users. Of these, 76.94% belong to the Verdes Campos region and 23.06% to the Entre Rios region. Regarding the type of unit in which the research took place, 42. 11% of respondents accessed conventional BHU, 42.02% Family Health Strategies and 15.87% basic integrated health units.
For data collection, the Epi-Info® 7.0 program was used on tablets with typing on the interface of the sociodemographic questionnaire (age, education, marital status, race, private health plan, means of transport used, number of children, employment, income and others) and the PCATool-Brazil instrument, in the adult version, with the saving feature after being completely filled out.
The PCATool-Brazil adult version was validated in Brazil according to the model presented by the Ministry of Health and measures the presence and extent of the four essential attributes and the three attributes derived from PHC. It is noteworthy that the present study analyzes the dimension of coordination of care (integration of care and information system), which is composed of 12 items in the adult version, divided into integration of care and information systems. 7 The data collection period was from February to August 2015. As adult users, who met the inclusion criteria, accessed health services, an invitation was made to participate in the study.
The responses were of the Likert type, with an interval of one to four. The possible answers for each of the items were:  hospital outpatient clinic (11.3%). This level of care was usually sought mainly by people belonging to classes whose monthly income per capita was low, and as income increased, the proportion of people who sought PHC decreased. In contrast, visits to private practices showed a positive association with income. 13 Most survey users have one or more children. A study found that women with low education and low income tend to get married or associate with partners earlier, start sexual life and have earlier births, with a greater number of children. 14 Thus, it contributes to the increase in the number of births, without, however, affecting the dizzying drop in absolute birth numbers.
In the present study, the coordination of care did not obtain a statistical difference in PHC between the models of care observed, under the evaluation of users. This result was also demonstrated in a study that compared the performance of the essential attributes of PHC based on the perception of users attended at BHU and FHS in a large city in Brazil, not identifying differences in the evaluation of conventional BHU and FHS regarding the studied attribute. 15 The coordination of care in this study obtained a value considered to be high in the different models of care, a reality found in other studies in which coordination obtained a value close to the ideal. 15,16 In another study, the coordination and integration of care obtained a low evaluation. 17 Already in an investigation that also analyzed the coordination of care integration, similarity was found in user satisfaction, in which most units obtained a high PHC score. 5 The indicator "proportion of users referred to specialists" had no significant difference between the different types of units, a result similar to that found in other studies. 18 Users positively evaluated questions regarding referrals, such as the

DISCUSSION
The predominance of females in the profile of users, regardless of the type of unit, is in line with findings evidenced in studies carried out in Espírito Santo and Porto Alegre-RS. 10,11 This refers to a social situation in which women assume a main role in the family in relation to health care, accessing health services more frequently, compared to men. Historically, in the view of common sense, the man is seen as a strong being, who hardly gets sick, with the female predominance looking for health services. 12 On the other hand, the data may reveal that the predominant demand for women in the services may be associated with the programs offered by the service, since in Brazil, historically, health policies have emphasized actions aimed at the maternal and child extent.
The study showed the predominance of married people in the three types of health units, which is in line with a research that obtained 59. 1% of married women. 10 This data is similar to that of another study, which found a predominance of females (89%) in family income, with the interval between one and two minimum wages being the most prominent. 5 Data from the Instituto Brasileiro de Geografia e Estastística (IBGE) revealed that in 2013, 27.9% of the Brazilian population had at least one private health plan. 13 When assessing adherence to the private health plan, the study showed that 25.86% of adult users have a private plan. This shows that 73.76% of adult users are assisted exclusively by SUS, highlighting the role and importance that this system plays in guaranteeing access and comprehensive care in health services in Brazil.
The 2013 IBGE National Health Survey supplementary health survey revealed that, in Brazil, 77.8% of resident people, when they needed health care, used to look for the same place, doctor or health service. PHC was the place most declared as sought (47.9%), followed by private practices (20.6%) and the  care network; better PHC resolution capacity, based on the allocation of resources and the expansion of services offered; and well-established reference and counter-reference along the therapeutic path. 18 Thus, health services must be guided by the principles of the HCN. These are polyarchic organizations of health service sets, linked together by a single mission, by common objectives and by a cooperative and interdependent action, which allow to offer continuous and integral care to a determined population coordinated by PHC. 3 In the coordination of care, the medical record constitutes an essential document for the development of coordination, the main record of the pertinent information of the user and the care provided and guarantees communication between the health team, aiming at comprehensive care. 19 The study revealed good evaluation by users in relation to their records and existence of medical records in consultations and medical services, data confirmed by another survey, in which the availability of family medical records during consultations was perceived as positive by users. 5 Users' permission to read or examine their medical records in this study was low. These data are opposed to those of another study, which obtained a positive evaluation. 9 The research made it possible to assess that in the dimension of coordination there are no significant differences in the evaluation by models of care in PHC. This result shows that in the 32 municipalities studied, which comprise two health regions, the FHS does not appear as a model of care that differs from the others, not presenting itself as a potential for changing the model of care.
This goes against what was expected at the time of the implementation of the FHS, which arose in response to the crisis of the hegemonic medical-clinical model, proposing a real change in the way of thinking and carrying out health actions. This is because the predominant care model in the country does not yet contemplate the principles of SUS, prioritizing care that is sometimes individualized, based on healing and medicalization, with low resolution and low social impact.

CONCLUSIONS
The dimension of the coordination of care, in the present study, was well evaluated, obtaining a high score in the different models of care. In addition, the study indicated that there was no statistical difference between them in PHC, as assessed by users. The results presented have important implications for the model of services evaluated and for public health care policies and reinforce the development of evaluative studies to improve the quality of PHC and the coordination of care. service's suggestion for the consultation with specialist and the knowledge of the PHC service on consultations with the specialized service. The assessment, however, was not positive in terms of PHC discussing with the user the different services to which he could be referred for the resolution of his health demand. In another study, the same variable showed a statistically significant difference between the BHU and the FHS, in which the highest average was found in the FHS, indicating that these professionals give more options for patient care locations. 17 Users interviewed from conventional BHU and integrated BHU positively evaluated the help in scheduling consultations with specialists, considering the values referring to the upper limit of the Likert scale. In the FHS BHU, this item was poorly evaluated. The questions referring to the reference and counterreference, such as: writing useful information to the specialist, monitoring the result of this consultation, in all types of study units were well evaluated, corroborating with data found in the literature. 5 Different result from another study whose reference and counter-reference showed low average in both models and did not report a statistically significant difference between the models studied. 17 In this study, the question regarding the service talking to the user about what happened during the consultation with the specialist had a low evaluation in the conventional BHU and FHS, but the integrated BHU, considering the upper limit of the Likert scale, was well evaluated. Users' analysis of the service's interest in the quality of care provided by the specialist was considered low in the three models of care.
Information sharing is a requirement when it comes to coordination of care, since it reduces unnecessary repetition and provides health professionals with access to service records from other providers and activates their involvement and integration. 18 In addition, the absence of the counterreferral strategy is a factor that contributes to the failure of the coordination of care, since users return to the service without knowing what has been done at other levels of care. Likewise, the PHC reference team is left without information if the treatment was carried out and/or completed. 5 The user, in seeking to meet the needs, tends to seek other doors of entry into the HCN, either with the explicit knowledge of the teams working in PHC, through transfers, either through direct access or self-referral. 2 The coordination of care plays an organizing role of assistance among the different professionals, services and levels of assistance necessary for recovery, maintenance and health promotion.
Some factors have an impact on the coordination of care in PHC. Among them, we highlight the increase in the role of general practitioners, related to management and accountability for the user's therapeutic path, throughout the