TUBERCULOSIS PULMONARY MDR AND CHALLENGES FOR CARE COORDINATION – EXPERIENCE REPORT

INTRODUCTION: The search concerned about of the experience of a family health team in the city of Rio de Janeiro about the care coordination of a patient diagnosed with pulmonary tuberculosis which has developed resistance to antibiotics. OBJECTIVE: The objective of this report is to share the experience of the team highlighting challenges and strategies found to ensure the continuity and care coordination across the multidrug resistance to antimicrobial therapy, and subsequent treatment for prolonged period. METHOD: It stands out as the main challenges identified by the team were the patient's own resistance to accept the directly observed treatment (DOT) over the years, religious influence interfering with the continuity of care, lack of family structure and support, lack of motivation of the patient facing regimen and takes to achieve the cure. As strategies has been planning regular home visits for all team of the Family Health Strategy and Health Support Unit Team Family, daily visits to perform the TDO by the Community Agent and visit three times a week by nursing technique, the construction of a single treatment plan and the strengthening of dialogue with professional of the referral hospital for shared care. CONCLUSION: We conclude that ensure care coordination and continuity of care about TB remains a challenge for family health team, especially in cases of multidrug. The role of the multidisciplinary team, the ongoing discussion of strategies and following a single treatment plan are care facilitators.