The Individualized Therapeutic Plan (PTS) is a tool of the Expanded Clinical Approach that promotes comprehensive, person-centered care in Primary Health Care. Its objective is to build, with the active participation of the user and the multidisciplinary team, a care plan that considers not only clinical aspects but also social, emotional, and subjective dimensions. This study reports the experience of constructing a PTS in the context of a medical residency in Family and Community Medicine at UBS Condor, Belém (PA). A descriptive study with a qualitative approach, conducted between February and July 2024. Data were obtained from medical records, field diaries, and team meetings. The case involved a patient with pulmonary tuberculosis, social vulnerability, insomnia, knee pain, dietary difficulties, and low visual acuity. The PTS was developed through the stages of expanded diagnosis, goal setting, division of responsibilities, and periodic reassessment. The construction of the PTS enabled the identification of multiple social determinants of health. The team established goals agreed upon with the patient, such as benzodiazepine tapering, physical rehabilitation, nutritional recovery, and ophthalmology referral. Community engagement (neighbors and community center) was essential to ensure food access, emotional support, and inclusion in recreational activities. The patient showed significant clinical improvement, adherence to proposed therapies, and strengthening of family and community bonds, despite initial resistance to some specialized referrals. The Individualized Therapeutic Plan proved to be a powerful strategy for promoting humanized, comprehensive, and shared care in Primary Health Care. Its application strengthened the bond between patient and team, improved quality of life, and demonstrated the importance of interprofessional work and a person-centered approach. This experience highlights the relevance of medical training oriented toward longitudinal and territory-based care, aligned with the principles of the Brazilian Unified Health System.
Miranda et al. (Sun,) studied this question.