Development and organization

The creation of an Evaluation Unit that certifies the lack of self-sufficiency and that makes multidimensional evaluations of patients’ needs in order to offer more personalized and more appropriate integrated interventions. This would be a valid support to specialists dealing with urgent intervention and primary aid in mantaining the therapy protocol.

Thus, when the practicioner takes a patient in charge, home assistance for serious disabled patients is then included in a therapy programme. The legal framework follows the guidelines of ART. 39 of DPR 484/96

The type of intervention varies based on the type of patients:

  • ADP: scheduling of regular visits for preventive care, prevention and rehabilitation interventions for patients who are unable to go the clinic.
  • Patients living in residential homes or collective houses
  • ADI

A clarifiying response on the renewed role of GPs should make reference to the “Continuing Care Service” system as suggested by the British Columbia-Canada.

Monitoring and primary aid tasks.

Upgrading from monitoring role and redefinition of professionalism using more modern and specialistic criteria. They become the “Tutors” of the clinical case, the selectors of the ADI intervention and the intermediators with the GP through a proper analysis of patients’ clinical status. Professional health care assistants then become the “Case Managers”.

For a better sinergy among the colleagues, patients might request a specialistic intervention after discussing it with their GP.

They manage the sufference demand: training, education and therapies.

This releases doctor from any emotional burden which is then carried by the field experts. Furthermore, the analysis of the “Patient System” allows the optimization of the intervention and avoids waste of resources.

They improve the discomfort filter with the institutions and administration.

It provides coordination the following services:

  • Medical specialists 24/7;
  • Diagnosis verification and clinical tests;
  • Personal health care assistance;
  • rehabilitation;
  • prostheses;
  • psychological support;
  • caring services;
  • intervention support and aid:
  • computerized communication system;
  • general practitioner with personalized computer control.

Therefore, Cleaning, Feeding, Control and Primary aid needs: health care assistance, social organization (payments, maintanance), Monitoring, Treatment (medicines, rehabilitation, specific medical and psychological therapies, etc.), identifying specific professional and technical figures.

It is known that on the territory there are  several public and private institutions such as:

  • Services Cooperatives;
  • Social and Catholic volunteers Associations;
  • Labs;
  • Multi-specialty clinics;
  • Short-term and long-term recovery clinics;
  • Accomodation centers, hotels, religious institutes.

They work independently without any coordination. This is how the fragmentation process patients undergo and waste of resources are mantained.

The system aims at overcoming the lack of organization in order to optimize the condition of people requesting health care help.