In the mid-2000s, Dr. Fábio Luiz Vieira was involved in the early implementation and coordination of a community-based home care service in the Campo Limpo district of São Paulo, Brazil. The initiative emerged within the context of the Brazilian Unified Health System (SUS), at a time when territorial care models and strategies to reduce unnecessary hospitalisation were gaining relevance in public health policy.
The service was developed as part of a broader effort to reorganise care delivery at the local level, focusing on continuity of care, multidisciplinary teamwork, and integration with primary care and other points within the health network. Home visits, clinical monitoring, case management, and coordination with community health teams were key operational elements of the model, aiming to improve access, safety, and patient-centred care in socially vulnerable urban territories.
Service Integration: Strategies for Comprehensive Home Care
Building on the foundations of the Community Home Care Program in Campo Limpo, a service integration model was formalised and presented at the VIII Brazilian Symposium on Home Care (SIBRAD), São Paulo, 2007. The model structured coordination across multiple actors — including the Home Care Service (SAD), the Home Hospitalisation Service (SID-HMCL), Family Health Strategy teams (PSF), and primary care units — through shared protocols, eligibility criteria, integrated care plans, and defined information flows. The experience demonstrated improvements in service articulation and continuity of care, and the associated experience report received second place in the “Experience Report” category at SIBRAD, organised by Hospital Israelita Albert Einstein. The poster is archived as an open-access academic contribution via Figshare (DOI: 10.6084/m9.figshare.31980096)
Eligibility Criteria and Minimum Integrated Care Plan
The experience contributed to academic and technical discussions on eligibility criteria and integrated care planning in home care services. These reflections were later documented in the scientific report Eligibility Criteria and Minimum Integrated Care Plan in a Home Care Service: Experience Report from Campo Limpo, São Paulo, which systematised operational lessons from the field and highlighted the importance of structured protocols and coordinated decision-making in community-based care delivery.
At a national level, innovative local experiences such as territorial home care services were subsequently analysed within broader policy initiatives. The publication Atenção domiciliar no SUS: resultados do laboratório de inovação em atenção domiciliar, produced through technical cooperation between the Brazilian Ministry of Health and the Pan American Health Organization, aimed to identify and disseminate successful practices capable of improving care models across the country.
This type of initiative reflects the evolution of home care as a complementary or substitutive modality within health systems, supporting integrated care pathways and contributing to more efficient use of hospital resources. The exchange of knowledge between municipalities and national technical teams helped consolidate home care as an important strategic component of health system organisation in Brazil.
The Campo Limpo experience represents an early example of territorial innovation in public healthcare delivery, combining clinical practice, service organisation, and academic reflection. It illustrates how locally driven initiatives can inform broader policy development and contribute to the continuous transformation of health systems.
For structured data and historical references, the service is also documented in open knowledge platforms such as Wikidata, which help connect institutional memory, academic production, and public health innovation narratives.