Genoa – «Better at home». By how much would waiting times in emergency rooms or for medical tests be shortened if people over 65 with chronic diseases had adequate home care? With visits from the family nurse, remote control of parameters, the possibility of having the most frequent tests done in the community home without having to go to the hospital or private clinics? This is the philosophy background that inspires much of the Regional operational plan on home care which is connected to the Pnrr.
The stated goal in the plan it is 41,000 people followed at home, all over 65 and suffering from the main chronic diseases: diabetes, bronchopneumopathy, heart disease and neurological diseases. An achievable goal, according to the Ligurian health leaders, if the stages envisaged by the Pnrr are respected with the construction of community houses and territorial operations centers which will coordinate the activity of the districts in the territories.
At the moment, according to the councilorship, in the various home care trials already activated in the five Local Health Authorities, patients followed up they are 26 thousand. There is the personnel problem, which affects all health sectors. But even on this the forecast is that from 2025-26 even the bleeding of doctors from the national health service could see a first turnaround.
“In many situations, the home proves to be the best place of care – explains the regional health councilor, Angelo Gratarola – We have to bring many activities to the area that inappropriately see citizens go to hospitals today, perhaps only to have tests examined by the specialist . This is done with the telemedicine and a population that is increasingly accustomed to technological tools, but also bringing the organization of care, check-ups, therapeutic plans and family nurses to the territories».
The regional plan operating system for integrated home care codifies and organizes patient care procedures according to the guidelines of the 2023-25 regional health and social plan, giving responsibility to the teams who will work in community homes: doctors, nurses, social workers. Once a patient suffering from a chronic disease is taken care of by the system, all the activities and information that fall within his health situation must be entered in a territorial computer file called “Folder at home”, in addition the activities of the territorial teams they will not need a prescription, but will be programmed for each patient in order to follow the evolution of the disease. All performance external ones, on the other hand (hospitalisation, a specialist visit) must in any case be included in the information folder.
The plan sets out in detail the objectives to be achieved in 2023: at the end of the year, 33,000 Ligurians over the age of 65 with chronic illnesses are expected to be involved in home care programmes. To reach over 40 thousand at the end of 2024. To get there, in addition to involving patients, it is necessary to reorganize the data collection system for taking charge, introduce the new social and health evaluation system starting from the first screening evaluation, integrate the telemedicine platform.
A job not least organizational: for example, the complete entry of the data on taking charge of patients over 65 admitted to hospital who need protected discharge must be put into the system; those of those involved in telemonitoring programmes; those of those who receive the non-self-sufficiency fund or those on the waiting list to enter an RSA.
The access point the courses could be the office of one’s general practitioner, or the community house. The activation of each treatment process will then be notified to the social and health district in which the patient lives and the Territorial Operations Center will organize the necessary assistance process depending on the subject, the disease, the therapies or rehabilitation to be done: the individualized care plan.
«Liguria it is among the eight regions that have achieved the goal assigned in 2022 – notes the commissioner Gratarola -. Each Local Health Authority has its own set target and is working to achieve it. There are many types of activities that we will bring to the area or directly to the patient’s home. Wanting to give some examples we can mention the world of non-oncological palliative care or that of neurological chronicities, but practically every person over 65 has to deal with one or more chronic diseases» and this, in the oldest region of Italy, places a significant burden on the health system.
«The resources of the Pnrr they help us set up the operations centres, in the purchase of computer programs for telemedicine, but there is a big cultural work to be done to overturn the concept of taking charge and organizing therapies: think if we had had during the Covid a tool such as the “Home folder” of each person with chronic diseases, we could have organized prevention much better, avoided many hospitalizations. Data and clinical histories are an important tool for the organization. It will take some time for people to get used to it, but it is a necessary revolution.’
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