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The Lazio region is located in the central part of Italy. With about 6 Million residents, it is one of the biggest Italian regions. Rome, the capital of Italy, is in the middle of Lazio and accounts for half of the regional population. More than 1.3 Million residents are aged 65 and over. The regional administration is broken down into five provinces. In Lazio, commercial activities comprise agriculture, industry, services, and tourism, which plays an important role.
In Italy, the National Health Service is organised at regional level. Each region has its own budget for the regional health care service and is in charge of the administration and organization of health care for all residents. In the Lazio region, there are ten local health units, which provide health care based on essential levels of care defined by the Italian Ministry of Health. Social services of the municipalities provide support to residents in poor socio-economic conditions. At local level, some services (especially social services) are outsourced to private organisations according to individual assistance plans at local level.
In the context of the VIGOUR project, we integrated care delivery by better linking patients and care providers through the implementation of a “therapeutic contract” following the present pilot phase of an ICT based platform.
In Lazio, VIGOUR focused on the local health unit of Viterbo, a health authority in the north of our region. The target population were patients affected by three chronic conditions (diabetes, heart failure, COPD). These conditions are managed through chronic care pathways.
The organisational model of care for chronic conditions is based on active and close-to-home services provided by multidisciplinary teams, including social services. Particular attention was paid to transitions in care at hospital discharge, as well as IT supported clinical networks and ambulatory services providing multidisciplinary care, in close collaboration with general practitioners and involving tertiary services such as community health centres, and multidisciplinary integrated evaluation units.
Ursula Kirchmayer: u.kirchmayer(at)deplazio(dot)it
vigour(at)empirica(dot)com
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| Marina Davoli | Ursula Kirchmayer | Mirko Di Martino | Chiara Marinacci | Nera Agabiti |