National Integrated Continued Care Network (RNCCI)

Having been created in 2006, by the Decree-Law No. 101/2006 of 6 June, the National Network of Integrated Continued Care is the result of a partnership between the Ministry of Labour, Solidarity and Social Security and the Ministry of Health.

The objectives of the RNCCI are to provide health care and social support in a continuous and integrated manner to people who, regardless of age, are in a situation of dependency. Integrated Continued Care focuses on the overall recovery of the person, promoting his/her autonomy and improving his/her functionality, within the situation of dependence.

The creation of the Integrated Continued Mental Health Care (CCISM) has allowed the RNCCI to be extended to people with mental health problems by contemplating the existence of psychosocial rehabilitative structures, responding to situations with varying degrees of psychosocial disability and dependence due to severe mental illness.

The following are users of integrated long-term care, citizens in the following situations:

• Temporary functional dependence;
• Extended functional dependence;
• Elderly with fragility criteria (dependency and illness);
• Severe disability, with strong psychological or social impact;
• Severe, advanced or terminal illness.

In general, the objective of the RNCCI is to provide integrated continuous care to people who, regardless of age, are in a situation of dependency.

Os objetivos específicos são:

• melhorar as condições de vida e de bem-estar das pessoas em situação de dependência, através da prestação de cuidados continuados de saúde e/ou de apoio social;
• promover a prestação de cuidados no domicílio às pessoas com perda de funcionalidade, sempre que este apoio domiciliário, garanta os cuidados terapêuticos e o apoio social necessários à provisão e manutenção do seu conforto e qualidade de vida;
• monitorizar todo o processo de internamento e ajustar os procedimentos à especificidade de cada doente;
• promover a qualidade e a eficácia da prestação de cuidados continuados de saúde e de apoio social;
• formar, qualificar e apoiar os familiares, ou prestadores informais, na prestação dos cuidados;
• garantir o correto funcionamento da RNCCI, articulando e coordenando com os diferentes níveis de atuação a resposta mais adequada às diferentes situações.

The basic principles of the RNCCI are::

• Individualized and humanized care provision;
• Ensure the articulation and continuity of care between different services, sectors and levels of performance;
• Equity in access and mobility between RNCCI typologies and teams;
• Proximity of care provision, through the empowerment of integrated services in the community;
• Multidisciplinary and interdisciplinarity in the provision of care;
• Comprehensive assessment of the needs of the person in a situation of dependency and periodic definition of objectives of functionality and autonomy;
• Promotion, continuous recovery or maintenance of functionality and autonomy;
• Participation of the user and his/her relatives or legal representative in the preparation of the individual intervention plan and co-responsibility in the provision of care;
• Efficiency and quality of care.

As bases da RNCCI assentam num modelo de garantia do direito da pessoa em situação de dependência:

• à dignidade;
• à preservação da identidade;
• à privacidade;
• à informação;
• à não discriminação;
• à integridade física e moral;
• ao exercício da cidadania;
• ao consentimento informado das intervenções efetuadas.

The RNCCI of general scope, contemplates the following response typologies:

• Convalescent Units;
• Medium Term and Rehabilitation Units;
• Long Term Units and Maintenance;
• Integrated Continued Care Teams - Home;

The RNCCI in the field of Mental Health, contemplates the following response typologies:

• Autonomy Training Residences;
• Autonomy Training Residences - Type A (Childhood and Adolescence);
• Occupational Partner Units;
• Occupational Partner Units - Type A (Childhood and Adolescence);
• Maximum Support Residences;
• Moderate Support Residences;
• Home Support Teams.

Hospitalization Units

Convalescence Unit - for stays up to 30 days

Aimed at people who no longer need hospital care, but because of a sudden illness or worsening of a chronic illness or disability, require health care which, because of its frequency, complexity or duration, cannot be provided at home.

A Unidade de Convalescença assegura:

• cuidados médicos permanentes;
• cuidados de enfermagem permanentes;
• exames complementares de diagnóstico, laboratoriais e radiológicos;
• prescrição e administração de medicamentos;
• cuidados de fisioterapia;
• apoio psicológico e social;
• higiene, conforto e alimentação;
• convívio e lazer.

Medium Term and Rehabilitation Unit (UMDR) - for hospitalizations of between 30 and 90 days

It is aimed at users who have temporarily lost their autonomy but who have rehabilitation potential and who need health care, social support, which because of its frequency or duration, cannot be provided at home.

A UMDR assegura:

• cuidados médicos diários;
• cuidados de enfermagem permanentes;
• cuidados de fisioterapia e de terapia ocupacional;
• prescrição e administração de medicamentos;
• apoio psicossocial;
• higiene, conforto e alimentação;
• convívio e lazer.

Long Term Unit and Maintenance (ULDM) - for stays of more than 90 days

It is aimed at users with chronic diseases or processes, with different levels of dependency and degrees of complexity, who are not able to be cared for at home or in another type of response. It provides social support and maintenance health care that prevent and delay the worsening of the dependency situation, favouring comfort and quality of life.

ULDM may also have admissions for the caregiver's rest (maximum 90 days per year).

A ULDM assegura:

• atividades de manutenção e de estimulação;
• cuidados de enfermagem permanentes;
• cuidados médicos;
• prescrição e administração de medicamentos;
• apoio psicossocial;
• controlo fisiátrico periódico;
• cuidados de fisioterapia e de terapia ocupacional;
• animação sociocultural;
• higiene, conforto e alimentação;
• apoio no desempenho das atividades da vida diária.

Integrated Continued Care Teams (ECCI)

It is aimed at users in a situation of temporary or long-term functional dependence, who cannot move autonomously, whose reference criterion is based on fragility, serious functional limitation, conditioned by environmental factors, with severe illness, at an advanced stage or terminal, throughout life, who meet conditions in the home that allow the provision of the integrated continuous care that they require:

• frequência de prestação de cuidados de saúde superior a 1 vez por dia, ou, prestação de cuidados de saúde superior a 1 hora e 30 minutos por dia, no mínimo de 3 dias por semana;
• cuidados além do horário normal de funcionamento da equipa de saúde familiar, incluindo fins de semana e feriados;
• complexidade de cuidados que requeira um grau de diferenciação ao nível da reabilitação;
• necessidades de suporte e capacitação ao cuidador informal.

As ECCI oferecem:

• cuidados domiciliários de enfermagem e médicos (preventivos, curativos, reabilitadores ou paliativos);
• cuidados de reabilitação;
• apoio psicossocial e de terapia ocupacional, envolvendo os familiares e outros prestadores de cuidados;
• educação para a saúde aos doentes, familiares e cuidadores;
• apoio na satisfação das necessidades básicas;
• apoio no desempenho das atividades da vida diária.

What are the types of continued care in Mental Health of RNCCI?

RAM- Maximum Adult Support Residence

The maximum support residence is a residential structure, located in the community, intended for clinically stabilized people with a high degree of psychosocial disability, unable to be treated at home due to lack of adequate family or social support. Its purpose is to provide care that prevents and slows down the worsening of the dependency situation.

RAMo- Moderate Support Residence

The moderate support residence is a residential structure, located in the community, intended for people with a moderate degree of psychosocial disability, clinically stabilized, unable to be treated at home due to lack of adequate family or social support. Its purpose is to provide care that allows the maintenance and development of the existing functionality, providing better quality of life and promoting socio-occupational integration.

RTA- RTA/A Autonomy Training Residence

The autonomous training residence is a residential unit, preferably located in the community, designed to develop psychosocial rehabilitation programmes for people with moderate and reduced levels of psychosocial disability, who are clinically stabilised and retain some functionality. It aims at the social and family reintegration of people with psychosocial disability, preparing them for their return home or, in the absence of adequate family or social support, for admission to other units and teams.

Autonomy Training Residence - Type A

Childhood and adolescence, presents the same characterization and purposes, intended for childhood and adolescence.

USO - Occupational Partner Unit

The Socio-occupational unit is located in the community, in its own physical space, being destined to people with moderate and reduced degree of psychosocial incapacity, clinically stabilized, but with dysfunctionalities in the relational, occupational and social integration area.

Occupational Partner Unit - Childhood and Adolescence

It presents the same characterization and purposes, aimed at childhood and adolescence.

Home Support Team (DSS)

The EAD develops the necessary activities in order to: maximize the autonomy of the person with psychosocial disability; strengthen its social support network through the promotion of meaningful interpersonal relationships; improve its social integration and access to community resources; prevent hospital admissions and admissions in residential units; signal and refer situations of decompensation to Local Mental Health Services and support the participation of families and other caregivers in providing care at home.

You can check the existing Units here.

If you are admitted to a National Health Service (SNS) hospital

Contact the department where you are admitted or the Senior Management Team (EGA) of that hospital.

The EGA of the hospital where the patient is admitted, is the team that analyses the patient's situation. If the EGA verifies that it has the necessary conditions to be forwarded to the RNCCI, it sends a proposal for admission to the Local Coordinating Team of the area of residence of the patient/family.

If you are at home, in a private hospital or other Institutions or Establishments

You should contact a member of the family health team (doctor, nurse and/or social worker) of the Health Unit in the area where you live who will assess the situation according to the criteria defined in the RNCCI and will send a proposal for admission to the Local Coordination Team in the same area.

How do you know if Social Security helps you to pay part of the RNCCI's expenses?

The user pays the costs related to the social support, and a part of this expense can be reimbursed by the Social Security. In this case the amount payable will depend on the household's income, which is calculated by the Local Coordination Team. The social security contributions are transferred directly to the institution where the patient is staying.

For more detailed information on resource condition, see Resource Condition Practical Guide.

Documents required for integration into the RNCCI:

•  Model AS 55-DGSS - Declaration of the National Network of Integrated Continued Care Social Security Co-payment. This can be downloaded or filled in computer by using the WEBSITE www.seg-social.pt.

The Document is available in the right side column associated with this page at Forms.

• Copy of valid identification document (Citizen's Card, Identity Card, Certificate of Civil Registry, Birth Certificate, Passport);
• Copy of the Social Security or other social protection system beneficiary's identification document;
• Copy of the Tax Identification Card (taxpayer number) of the user and of the household members;

How much do you pay?

• The internment in a Convalescence Unit is free for the user; 
• The ECCI home support is free for the user;
• Only in Medium Term and Rehabilitation Units and in Long Term and Maintenance Units, the user is reimbursed the costs related to social support, according to his/her income, in complementarity with Social Security;
• In all types of RNCCI, health care costs are assumed by the National Health Service, or by other health subsystems;
• Costs referring to social support are shared by the user, according to their income, in addition to the Social Security;
• The Unit will only charge health and social care and support services for the daily amount agreed upon at the time of signing the Term of Acceptance of the Hospitalization;
• Other expenses, which are not part of the agreed care and services, are the exclusive responsibility of the user, when requested by him/her;
• It is also envisaged that a contract for the provision of services will be concluded at the time of admission, between the user and the provider, reinforcing the underlying commitments in the Term of Acceptance, transposing into writing the rights and duties, including the mode of payment.

What income is considered?

For the household income to be taken into account when determining the amount to be paid by the user and for the purpose of calculating the social security contribution, please refer to the  Practical Guide National Network of Integrated Continued Care, in the right-hand column linked to this page.

Renew the proof of income every year

At the end of each year you have to make a new proof of income (present Model AS 55-DGSS Declaration of the National Network of Integrated Continued Care Social Security Co-payment).

Change the composition of the household

When there are changes in the household, the user should immediately inform the Unit where they are receiving care, so that it can inform the Local Coordinating Team, which will review the calculation of the amount to be paid.

You must submit the Model AS 55-DGSS - National Network Declaration of Integrated Continued Care Social Security Co-payment.

Comply with the Internal Regulations

Users and families are also obliged to comply with the Internal Regulations of each unit/team.

End of RNCCI Continuous Care Provision

The RNCCI's continued care ends when:

• The user is discharged from the Unit;
• The user no longer needs the support of the home team and is discharged from it.

The Social Security does not assist users in the following situations:

• When they’re discharged from the unit;
• If they do not renew the proof of income;
• If there is a change in the composition of the household, they do not submit the Model AS 55-DGSS - Declaration of the National Network of Integrated Continued Care Social Security Co-payment;
• When false statements are made.

As entidades promotoras e gestoras das unidades e equipas da Rede revestem uma das seguintes formas:

• Entidades públicas do Serviço Nacional de Saúde;
• Instituições Particulares de Solidariedade Social e equiparadas, ou que prossigam fins idênticos;
• Entidades Privadas.

A RNCCI é coordenada por quem?

A nível nacional existe uma coordenação conjunta dos Ministérios do Trabalho, Solidariedade e Segurança Social e da Saúde, designada por Comissão Nacional de Coordenação da Rede Nacional de Cuidados Continuados Integrados, com dois coordenadores, indicados por cada um dos ministérios e representantes das seguintes entidades:

• Administração Central do Sistema de Saúde, I. P.;
• Direção-Geral da Saúde;
• Instituto da Segurança Social, I. P.;
• Direção-Geral da Segurança Social;
• Gabinete de Estratégia e Planeamento do Ministério do Trabalho, Solidariedade e Segurança Social.

As competências desta Comissão Nacional de Coordenação, são as previstas no Despacho nº 176-D/2019 de 4 de janeiro.

Regional Coordinator Teams (ECR)

The coordination of the network at a regional level is ensured by five teams, one for each Health Region, constituted, respectively, by representatives of each Regional Health Administration and ISS District Centers, under the terms defined by Joint Order No. 19 040/2006, of 19 September.

The ECRs liaise with the coordination at national and local levels and ensure the planning, management, monitoring and evaluation of the Network.

Local Coordinator Teams (ECL)

The coordination of the network at a local level is ensured by multidisciplinary teams, comprising at least from the Social Security sector a social worker, from the Health sector, a doctor and a nurse, and, whenever necessary, a representative of the local authority.

The constitution, organization and operating conditions of the teams that ensure the coordination of the Network at a local level are defined by Joint Order No. 19 040/2006 of 19 September.
The ECLs liaise with the ECR of the respective region, ensure the monitoring and evaluation of the network at a local level, as well as the articulation and coordination of resources and activities, within its scope of reference.

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