The aim of this study was to create a project to be applied in the evaluation of the population that carries these chronic diseases in the municipality and to develop strategies for continuous care control according to individual needs, through risk stratification, formation of support groups, training of professionals and offer multidisciplinary attention. The intervention involves the patients enrolled in the Family Health Strategy unit and all the spontaneous patients attended by the UBS of Altamira do Paraná, with a chronic disease such as SAH and DM TYPE II. With all measures together we seek to increase the longevity of these patients, reducing comorbidities resulting from poor health control and improving quality of life. In addition, we can reduce the costs of hospitalizations, medications and procedures, and make patients who do not have the disease working on their prevention daily, avoiding an increase in the incidence of type II DM and SAH in our country.
