DESK REVIEWS | 04.03.09. (How) does the policy document support integrated care?

DESK REVIEW | 04.03.09. (How) does the policy document support integrated care?

Yes. The “Technical Guidelines for Implementing a Healthcare Pathway for Integral Health for Older People” is a document that supports integrated care in the Brazilian Unified Health System – SUS. This document explains that the government provides a “healthcare notebook” for older people, in which each older person should have her health information recorded. Based on this information, the person then becomes subject to a multidimensional assessment which considers physical, psychological, and emotional aspects of a person’s life in order to offer quality healthcare to each individual person. Based on these two tools, a “Person-Centered Therapeutic Plan” (Programa Terapeutico Singular – PTS) is tailored according to the needs and personal situation of each patient aiming at delivering integrated care, education, and better quality of life (Brazilian Ministry of Health, 2018e).


Brazilian Ministry of Health. (2018e). Orientações Técnicas para a Implementação de Linha de Cuidado para Atenção integral à Saúde da Pessoa Idosa no Sistema Único de Saúde—SUS. Ministério da Saúde do Brasil.

The policy document states the target to implement standard operational procedures across all healthcare facilities. Furthermore, the document emphasises the standardization of instruments, the value of screening, diagnosis, and treatment of people with dementia in primary healthcare facilities and through appropriate referral to secondary and tertiary healthcare facilities. Secondary and tertiary healthcare services are expected to provide integrated geriatric services and neurorestoration services (Ministry of Health Republic of Indonesia, 2015b).


Ministry of Health Republic of Indonesia. (2015b). National Strategy: Management of Alzheimer and Other Dementia Diseases: Towards Healthy and Productive Older Persons. Ministry of Health Republic of Indonesia.

It emphasises the need for an integrated care model involving all levels of the national health system, as well as the development of a training, evaluation and care model for primary caregivers and family members. On the other hand, the document aims at generating an inter-institutional network for the updating and feedback of personnel dedicated to the care of the person with dementia.