Abstract

Chronic diseases need ongoing care. The paradigm of continuing care requires organization that facilitates integrated interventions among the various community and hospital-based services and which minimizes the fragmentation of care. There is a need to create a unified system of medical and social services to coordinate all the existing organizational entities and assure continuity of care.

The study proposes to improve the continuity of care in fragile, complex patients with chronic diseases by providing indications that favor the diffusion of the most efficient organizational practices. In the study the patients and health professionals together define a territorial organizational model for both efficacious and efficient continuing care. It is a pilot study which could be broadened beyond the areas studied to have an impact on health care organization more generally.

Qualitative research was conducted in two urban centers in northern Italy (Brunod, Manoukian in Colucci, 2008). It analyzed the organizational models capable of providing both efficacious and efficient care from the perspective of patients and their health care professionals. Interviews with fragile, complex patients (Barthel 3) – excluding oncologic and psychiatric patients – served to identify pathways to care from one service to another. It analyzed cultural models already in use by health professionals and the ability of patients to understand the pathways formulated on the basis of their disease characteristics and functional status; the organizational variables and the control of decision-making processes between territory and hospital.

The study produced an analysis of existing organizational models, a comparison between territories and setting of care, and the input of patients and health professionals. It identified weak points as well as effective organizational processes which helped to maintain communication among the various figures involved the the continuing care process. As well it helped to discover innovative and original methods of intervention and to foreshadow some organizational models capable of firmly overseeing processes of care between hospitals and territories and between families and local services.

The Italian National Health Service, founded on the concept of universality and at no cost to patients today is changing both for epidemiologic reasons (WHO Europe 2014) and for better allocation of resources, as well as new guidelines in cost standardization. An organizational change is required in the direction of greater efficacy and efficiency in terms of continuity of care and assistance. At the regional level the recent reforms in the health care and social assistance sectors have resulted in a shifting of health care and social assistance services from hospitals to the territories in a system not yet sufficiently organized or ready to assume care of a clientele in a form different than that offered by hospitals, either acute care or long-term. In consideration of the epidemiologic data and the reduction of resources at the national level a trend toward territorial health care has appeared (Gori, 2014). This study highlights other dimensions that make an impact on the development of an efficacious and efficient health care policy.

Slides