Piedmont (north-west of Italy) is a mainly mountainous and hilly region and counted about 4,375,865 inhabitants for 1,180 municipalities. Its economy is characterised by both industrial and agricutural sectors. During the second half of the last century, Piedmont became a destination place for internal immigrants coming from other Italian regions.
In the last, three, four years, primary care has been reinforced through new organizational models, such as Community Health Centres (CHC), where multi-professional teams work for primary and specialized care through (spatial and functional) continuity of services, professional relation, and social-health integration. Today, 64 CHCs are regularly operating, offering care, social and socio-health services in urban and rural/mountain contexts. A stronger implementation of territorial care was needed, based on a very high risk of inappropriate use of secondary care resources, delivered by hospital trusts in the Region.
The challenges of the next years: promotion of functional social-health integration among professionals in the CHCs; strengthening the professional roles managing chronic and frail patients’ (i.e. Family and Community Nurses - FCN); implementation of the regional Chronic Care Plan.
With the help of VIGOUR we were able to scale-up collaborative service models to bring together the usual silos of social care, health care and informal support, thereby benefiting from ICT-enabled, integrated health and social care.
Complex, interlaced social and health needs of patients are already addressed by different services in CHCs of which, the most important is the socio-health Single Point of Contact (SPC). Integration actions were implemented: activation of socio-health SPCs in all CHCs; inclusion of general practitioners and pediatricians; introduction of FCNs; digital innovation of data and information systems and development of telemedicine; experimentation of innovative services / practices in the care and social fields
The involvement and the participation of regional and community stakeholders, in planning and implementation processes was also a key factor: policy makers, health directors, health and social workers, municipal authorities, enterprises, associations, and citizens.
Valeria Romano: v.romano(at)ires.piemonte(dot)it
Silvia Rizzi: silvia.rizzi(at)regione.piemonte(dot)it