Multiprofessional Care for Chronic Conditions in Brazil's SUS: Key Challenges and Opportunities for Comprehensive Health Care

Copyright © ISRG Publishers. All rights Reserved. DOI: 10.5281/zenodo.17960097 378 ISRG PUBLISHERS Abbreviated Key Title: ISRG J Arts Humanit Soc Sci ISSN: 2583-7672 (Online) Journal homepage: https://isrgpublishers.com/isrgjahss Volume – III Issue -VI (November-December) 2025 Frequency: Bimonthly Multiprofessional Care for Chronic Conditions in Brazil’s SUS: Key Challenges and Opportunities for Comprehensive Health Care Siglia Sousa de França1*, Siglia Sousa de França2, Adenilson Lima e Silva3, Adriana Marinho Pereira Dapont4, Cristiane de Castro Barcelos5, Anelise Nogueira de Lima6, Carlos Barros Marinho Filho7, Ludmila Vohryzek Sommer8, Felipe Flavio Silva9 1, 2, 3, 4, 5, 6, 7, 8 Wagner de Aguiar Raupp Rua Joao Tobias 15 38401066. Affiliation: PHD in Public Health – Universidad de Ciencias Empresariales y Sociales | Received: 01.12.2025 | Accepted: 06.12.2025 | Published: 17.12.2025 *Corresponding author: Siglia Sousa de França Wagner de Aguiar Raupp Rua Joao Tobias 15 38401066. Affiliation: PHD in Public Health – Universidad de Ciencias Empresariales y Sociales Abstract This study examines the importance of multiprofessional teams in delivering comprehensive care to individuals with chronic diseases within the Brazilian public health system. Chronic conditions require continuous and coordinated actions that address biological, psychological, social, and environmental factors, which makes isolated or strictly biomedical interventions insufficient. The literature indicates that collaborative team practices enhance clinical decision-making, strengthen continuity of care, and improve health outcomes. This narrative review synthesizes evidence from national and international studies published over the past five years, selected through searches in major health databases using controlled descriptors and related terms in multiple languages. Eligible studies addressed multiprofessional work in chronic disease management and discussed challenges, collaborative practices, and impacts on care quality. The findings reveal three central themes. First, the organization and integration of multiprofessional work are essential for building shared therapeutic plans, promoting interprofessional communication, and ensuring coordinated care across different points of the health network. Second, teams face significant structural, organizational, and relational barriers, including insufficient resources, fragmented care pathways, limited information systems, power asymmetries, and communication difficulties. These challenges restrict the implementation of collaborative practices and compromise continuity of care. Third, the literature highlights substantial potentialities of multiprofessional work, such as broader clinical assessments, more humanized and contextualized interventions, prevention of complications, and reduction of avoidable hospitalizations. Multiprofessional collaboration also fosters ongoing learning and strengthens collective Copyright © ISRG Publishers. All rights Reserved. DOI: 10.5281/zenodo.17960097 379 Introduction Noncommunicable diseases represent one of the major contemporary challenges for health systems worldwide, especially in lowand middle-income countries. In Brazil, this scenario is particularly complex due to population aging, epidemiological transition, and the persistence of social inequalities that shape illness patterns and hinder continuous access to health services. In this context, the Unified Health System (Sistema Único de Saúde – SUS) plays a central role in formulating strategies for comprehensive care, seeking to ensure articulated, equitable, and effective responses to the growing demands associated with these conditions (Castro, Rebelo & Santana, 2024). Given the multifactorial nature of chronic diseases—which involve biological, behavioral, psychological, social, and environmental dimensions—it becomes evident that isolated interventions centered on a single professional or on traditional biomedical models are insufficient (Moura et al., 2024; Persilva et al., 2024). The complexity of these clinical conditions requires interdisciplinary actions, collective planning, and collaborative practices capable of articulating different fields of knowledge. Thus, multiprofessional work emerges as a key component in strengthening comprehensive care, continuity, and coordination across the Health Care Network (Rede de Atenção à Saúde – RAS) (Fonseca, 2025). However, the effective implementation of multiprofessional work faces limitations that range from structural barriers—such as insufficient resources and organizational weaknesses—to relational challenges, such as role conflicts, communication barriers, and difficulties in constructing shared therapeutic projects. At the same time, the literature highlights significant potentialities of this approach, including increased clinical resolvability, improved care quality, strengthened patient–provider relationships, and enhanced support for self-care (Abbade, 2024). Considering this scenario, it becomes essential to analyze how multiprofessional teams contribute to the implementation of comprehensive care for individuals with chronic diseases in the SUS, as well as to identify the main challenges and potentialities surrounding these practices. Thus, the objective of this study is to analyze the importance of the multiprofessional team in providing comprehensive care to people with chronic diseases in the SUS, identifying the structural, organizational, and relational challenges involved, as well as the potentialities and impacts of this approach for enhancing the quality of care. Methodology This study is a narrative literature review, a methodological approach that allows the collection, analysis, and synthesis of available evidence on a specific phenomenon. This strategy enables the integration of studies with different designs and research methods, promoting a broad, critical, and contextualized understanding of the role of multiprofessional teams in providing comprehensive care to individuals with chronic diseases in the SUS. The guiding question of this review was: How does the work of multiprofessional teams contribute to comprehensive care for people with chronic diseases in the SUS, considering its challenges and potentialities? The literature search was conducted in the PubMed, SciELO, and LILACS databases, selected for their relevance in public health, chronic disease care, teamwork, and health policy research. These databases offer extensive coverage of national and international studies related to comprehensive care, collaborative practices in health, and the functioning of the Unified Health System. Controlled descriptors and free-text terms were used in Portuguese, English, and Spanish, combined using the Boolean operators AND and OR. The main search terms included ―multiprofessional team,‖ ―chronic diseases,‖ ―comprehensive care,‖ ―Brazilian Unified Health System,‖ ―teamwork in health,‖ and ―primary health care.‖ Studies published within the last five years were included if they addressed the work of multiprofessional teams in the care of people with chronic diseases, emphasizing challenges, potentialities, collaborative practices, and impacts on the comprehensiveness of care within the SUS. Excluded from the review were duplicate studies, non-systematic reviews, editorials, letters to the editor, experience reports, and studies that did not directly address multiprofessional work in chronic disease care or were not aligned with the SUS context. The analysis of selected studies was conducted rigorously, considering thematic relevance, methodological quality, and each study’s contribution to understanding collaborative health practices, the challenges faced by teams, and strategies that enhance comprehensive care. The synthesis of data allowed the identification of recurring thematic categories, which supported the organization of the results and guided the critical discussion about the role and importance of multiprofessional teams in addressing chronic diseases, highlighting factors that facilitate or hinder their performance in the SUS. Results and Discussion Based on the analysis of the selected studies, it was possible to identify a set of recurring elements that reflect the complexity of caring for individuals with chronic diseases in the context of the SUS and the centrality of multiprofessional work in this process. The evidence indicates that collaborative team practices directly influence care quality, continuity of care, and health outcomes. In this sense, three thematic categories emerged that synthesize the main findings in the literature: (1) Organization and integration of multiprofessional work in chronic disease care; (2) Structural, organizational, and relational challenges for multiprofessional practice in the SUS; (3) Potentialities and impacts of multiprofessional care on the comprehensiveness of attention to chronic diseases. These categories enable a critical understanding competencies within teams. Overall, this review demonstrates that multiprofessional work is a strategic component for improving comprehensive care for chronic diseases in Brazil. Advancing this approach requires investments in workforce development, organizational integration, information technologies, and participatory management to ensure equitable, coordinated, and personcentered care. Keywords: Multiprofessional Care; Chronic Diseases; Comprehensive Health Care; Interprofessional Collaboration Copyright © ISRG Publishers. All rights Reserved. DOI: 10.5281/zenodo.17960097 380 of how different factors interact to facilitate or hinder the effectiveness of teamwork in chronic disease management. Organization and Integration of Multiprofessional Work in the Care of Chronic Diseases The organization and integration of multiprofessional work constitute structuring dimensions for the effective delivery of comprehensive care to individuals with chronic diseases within the Unified Health System (SUS). Chronic conditions, due to their complex nature, require continuous, coordinated, and intersectoral actions, which make approaches based exclusively on uniprofessional practices or traditional biomedical models unfeasible. In this context, the studies analyzed indicate that the structuring of multiprofessional teams, articulated around a common therapeutic project, is an indispensable strategy for expanding the resolutive capacity and comprehensiveness of health actions (Castro, Rebelo & Santana, 2024; Abbade, 2024). Shared planning stands out as a fundamental axis of this organizational process. It is a practice that goes beyond the simple division of tasks, involving the collective construction of broader diagnoses, the consensual definition of therapeutic goals, and the negotiation of responsibilities among professionals. This approach supports the development of care plans centered on the user’s unique needs, integrating clinical, functional, psychosocial, and social aspects of illness. In addition, it strengthens the principle of co-responsibility, a central element in the logic of comprehensive care advocated by the SUS (Fernandes, 2023; Fonseca, 2025). Interprofessional communication also emerges as a structuring requirement for the effective functioning of the teams. Studies show that continuous, systematized, and horizontal communication contributes to joint decision-making, reduces care fragmentation, avoids therapeutic redundancies, and promotes longitudinality. Strategies such as team meetings, case discussions, electronic medical record systems, and structured communication protocols strengthen the flow of information and enhance the capacity for care coordination (Leal et al., 2024; Marques, 2023). Regarding care models, longitudinal care and integrated clinical management have stood out as essential tools for monitoring chronic conditions. Longitudinality—understood as the continuity of the therapeutic relationship over time—enables the development of bonds and increases the effectiveness of educational interventions and supported self-care. Integrated clinical management, in turn, enables an articulated approach linking preventive, curative, rehabilitative, and palliative actions, ensuring that users move in a coordinated way through the various points of the Health Care Network (RAS) (Figueiredo, Ceccon & Figueiredo, 2021). Interdisciplinary interventions represent an advance over mere parallel multiprofessional work. By promoting the synthesis of knowledge and the sharing of clinical rationalities, these interventions allow teams to overcome disciplinary fragmentation and produce more qualified responses to the complex needs of chronic diseases. Accordingly, the literature shows that the integrated organization of teams not only enhances therapeutic adherence and improves clinical outcomes, but also strengthens the effectiveness of the SUS by materializing the principles of comprehensiveness, care coordination, and humanization (Lopes, 2023; Bitencourt, 2024). Structural, Organizational, and Relational Challenges for Multiprofessional Practice in SUS The challenges surrounding multiprofessional practice in caring for people with chronic diseases in the SUS are multiple and interdependent, involving structural, organizational, and relational dimensions that directly influence the teams’ ability to provide comprehensive, continuous, and qualified care. The literature indicates that these challenges are not merely occasional barriers, but expressions of historical and structural weaknesses of the Brazilian health system, which particularly affect the management of chronic conditions (Ramos, 2023; Brilhante et al., 2024). From a structural perspective, limitations related to insufficient material, technological, and human resources are notable. The shortage of specialized professionals, high staff turnover, precarious employment relationships, and unequal availability of supplies and technologies across regions and services constitute significant obstacles to consolidating collaborative practices. This reality compromises continuity of care and hinders the implementation of care models centered on longitudinality and integrated management of chronic conditions (Pires, Ribeiro & Cruz, 2024). At the organizational level, one observes the persistence of management models and work processes still strongly influenced by fragmented and hierarchical logic. The absence of well-defined care pathways, low integration among points in the Health Care Network (RAS), difficulties in care coordination, and poor articulation among primary, specialized, and hospital care contribute to discontinuity in the follow-up of people with chronic diseases. Moreover, limitations in the adoption of communication tools and interoperable electronic medical records reduce the efficiency of information exchange and hinder longitudinal monitoring of users (Fonseca, 2025). Regarding relational challenges, the literature highlights tensions and asymmetries inherent to interprofessional dynamics, such as competency conflicts, disputes over professional boundaries, differing care perspectives, and difficulties in building a shared therapeutic project. Communication barriers, lack of mutual recognition among professional knowledge bases, and gaps in training for interprofessional work also compromise effective cooperation within teams. These challenges directly affect the ability to produce truly interdisciplinary practices and limit the transformative potential of multiprofessional work (Moura et al., 2024; Salustino et al., 2022; Abbade, 2024). The combination of these elements reveals that multiprofessional practice in the SUS faces obstacles that transcend the technical dimension, reaching macro-structural, epistemological, and cultural aspects. Overcoming these challenges requires continuous investments in workforce training policies, strengthening participatory management, incorporating information and communication technologies, and especially promoting an organizational culture that values interprofessionality as a guiding principle of health practice. Addressing these barriers is therefore essential for ensuring that chronic disease care is integrated, resolutive, and centered on users’ needs (Malta et al., 2020; Persilva et al., 2024). Potentialities and Impacts of Multiprofessional Care on Comprehensive Attention to Chronic Diseases The potentialities of multiprofessional work in caring for people with chronic diseases within the SUS are widely recognized in the literature and constitute essential elements for consolidating comprehensive care and improving health work processes. The Copyright © ISRG Publishers. All rights Reserved. DOI: 10.5281/zenodo.17960097 381 multiprofessional approach—especially when structured around collaborative and interdisciplinary practices—expands the capacity of teams to respond to the multiple dimensions involved in the management of chronic conditions, including clinical, psychosocial, functional, behavioral, and socioenvironmental aspects (Persilva et al., 2024). One of the main potentialities identified is the expansion of service resolutivity, as the diversity of professional competencies enables the development of broader diagnoses, the implementation of more comprehensive interventions, and the use of diverse therapeutic strategies. This plurality of knowledge increases the effectiveness of care and reduces unnecessary referrals, strengthening Primary Health Care as the care coordinator within the Health Care Network (Fonseca, 2025). Another relevant impact relates to strengthening the bond and longitudinality between teams and users. Joint action by different professionals enables more humanized approaches that take into account the life context, clinical history, socioeconomic conditions, and preferences of each person. This proximity fosters trustbuilding, essential for encouraging treatment adherence, promoting lifestyle changes, and supporting the development of self-care— central components in addressing chronic diseases (Castro et al., 2024). The literature also highlights that multiprofessional work contributes significantly to reducing complications and preventable hospitalizations by enabling continuous user monitoring, early management of exacerbations, and preventive action based on educational practices and systematic follow-up. These actions directly improve health indicators, reduce healthcare costs, and increase system efficiency (Fonseca, 2025). At the organizational and systemic level, interprofessionality strengthens care coordination and integration, enabling greater articulation among different points of the Health Care Network. This supports the development of more consistent care pathways, rational use of resources, and more fluid care flows, essential aspects for ensuring continuity of treatment across different stages of chronic illness (Freitas et al., 2024). The pedagogical potential of multiprofessional work stands out, as it contributes to ongoing in-service training, supports knowledge exchange, enables critical reflection on practices, and promotes the development of collective competencies. This educational dimension strengthens a culture of collaboration and acts as a mechanism for the continuous qualification of teams, directly impacting the quality of care delivered (Gomes, 2022). Thus, multiprofessional care stands as a fundamental tool for achieving comprehensiveness in SUS, promoting more equitable, efficient, and user-centered practices while strengthening the health system as a whole (Szwarcwald, Stopa & Malta, 2022); Abbade, 2024). Conclusion The literature shows that multiprofessional team work is fundamental for delivering comprehensive care to people with chronic diseases within the Unified Health System. Integrating different bodies of knowledge and professional practices makes it possible to understand the health–disease process in its complexity, overcoming care fragmentation and enhancing the responsiveness of health services. Based on the guiding question of this study, it becomes evident that the contributions of multiprofessional work manifest both in clinical qualification and in the organization of care, strengthening essential dimensions such as longitudinality, coordination, humanization, and the promotion of supported self-care. Fragmentation across points of the Health Care Network, poor communication, and the persistence of hierarchical models constitute significant obstacles to building shared therapeutic projects and ensuring continuity of care. 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