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OBJECTIVE: To propose an interdisciplinary approach in Community Health through a model based on Home Health Care. DESIGN: A prospective study programmed in two periods: a cross sectional study for data collection followed by home assistance for the health problems detected. METHODS: 100 families (570 inhabitants) were randomly submitted to a clinical, nutritional and laboratory examination in order to detect major health problems. Afterwards the same professional team took care of 10 families in health promotion counseling and illness treatment. RESULTS: This study shows that 84% of the patients in whom a health abnormality was detected were not aware of their illness. The population was mainly affected by hypertension, hypercholesterolemia, hypertrigliceridemia, and anemia. None of these problems were listed as the main causes of consultation in a local center belonging to the traditional health services. Almost 70% of the inhabitants consumed a daily diet with less nutrients and calories than recommended. The project included health care for all family members and free drugs provision for all illnesses detected. Ninety-eight percent of patients had a proper and continuous follow up of their illness for a 3 year period, compared with a 31% follow up provided by the traditional health care organization. CONCLUSIONS: This work shows an integrated effort by the University, health centers, and all health care disciplines to propose an alternative program that personalizes attention and moves health care from Institutions to people's own homes. This model improved community health conditions, had a high impact on illness follow up and increased health care accessibility.

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Objetivo. Proponer un abordaje interdisciplinario de la atención de la salud centrado en los hogares y comparar la morbilidad detectada mediante dicho enfoque, con aquella objetivada en el sistema sanitario tradicional. Materiales y métodos. Estudio prospectivo con diagnóstico de situación (mediante encuestas socioeconómicas, nutricionales y examen físico); y posterior acción comunitaria sobre 100 hogares de la zona (570 personas), elegidos en forma aleatoria. Resultados. Los datos mostraron una población afectada por enfermedades como hipertensión arterial, hipercolesterolemia, anemia y malnutrición; mientras que el modelo sanitario tradicional registró como prevalentes otras enfermedades totalmente diferentes a las anteriores. Además, el 84% de los individuos con alguna patología, no percibió la enfermedad.Después del diagnóstico inicial, se realizó una acción continua, en los planos de promoción de la salud, educación, atención y monitoreo de las patologías detectadas y fabricación y dispensación gratuita de medicamentos para tratamientos completos durante 36 meses. El seguimiento de los pacientes se cumplió en un 98% durante dicho período, en comparación con el 31% logrado por el sistema sanitario tradicional.Conclusiones. En este trabajo se muestra a un grupo interdisciplinario en una propuesta alternativa para la atención de la salud, la cual traslada el eje desde los servicios instalados, que esperan pasivamente ser utilizados, a una más activa que pone en el centro los propios hogares, basando las acciones en las necesidades, logrando tener un mapa real de las patologías prevalentes, incrementando la accesibilidad a sus controles periódicos

Objective. To propose an interdisciplinary approach in Community Health through a model based on Home Health Care. Design. A prospective study programmed in two periods: a cross sectional study for data collection followed by home assistance for the health problems detected. Methods. 100 families (570 inhabitants) were randomly submitted to a clinical, nutritional and laboratory examination in order to detect major health problems. Afterwards the same professional team took care of 10 families in health promotion counseling and illness treatment. Results. This study shows that 84% of the patients in whom a health abnormality was detected were not aware of their illness. The population was mainly affected by hypertension, hypercholesterolemia, hypertrigliceridemia, and anemia. None of these problems were listed as the main causes of consultation in a local center belonging to the traditional health services. Almost 70% of the inhabitants consumed a daily diet with less nutrients and calories than recommended. The project included health care for all family members and free drugs provision for all illnesses detected. Ninety-eight percent of patients had a proper and continuous follow up of their illness for a 3 year period, compared with a 31% follow up provided by the traditional health care organization. Conclusions. This work shows an integrated effort by the University, health centers, and all health care disciplines to propose an alternative program that personalises attention and moves health care from Institutions to people’s own homes. This model improved community health conditions, had a high impact on illness follow up and increased health care accessibility

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