New models to take care of frail older people from the hospital to the territory and from the territory tot he hospital: case management and quality of life.

Country:
Italy

Sub-programme of a wider initiative or programme:

To create an informative curriculum for the coordinator of the case – case manager- through an integrated network of services for frail older people. To create a Silver Code for the Emergency Room’s Triage and to evaluate its influence on physical functions, quality of life and mortality. To try out an innovative way to take care of frail older people through an integrated network: case management- guardian angel.

Official identification number or abbreviation:

Duration:

From March 2009 to March 2012

Funding budget:

500,000 euro

Homepage:

Funding body / financing organisation:

Università Cattolica del Sacro Cuore – Centro Medicina dell’Invecchiamento – Roma Regione Veneto Regione Toscana Regione Lazio Regione Sicilia

Challenges and objectives:

Main objective. The main objective will be reached through the following specific objectives: - to establish a formative syllabus for the professional responsible for the frail older people continuous health care - to identify and evaluate costs and benefits of a “silver code” for the frail older people hospital access - to elaborate a risk chart of frail older people disability; - to guarantee a continuous health care for frail older people, trying out new assistance models based on “case management”; it will be useful to individuate a new professional “Guardian Angel- Case Manager” - the final objective will be to demonstrate that a good health care pathway, from the hospital access (“Silver Code”) through the discharge, to the territorial services (“Guardian Angel”), will be useful to improve the quality of life of frail older people, to reduce their physical, cognitive and behavioural disability and meantime to reduce the socio-sanitary costs.

Thematic areas / main focuses:

To take care of frail older people during the transition from the hospital to the territory and from the territory to the hospital

Related to Working Group(s):
Social Systems & Welfare

Foreseen results and outcomes:

The outcomes are: - case manager’s curriculum studiorum (Objective 1) - to develop, validate and improve the „Silver Code“ to identify frail older people coming to the Emergency Room (Objective 2) - to create an integrated assistance network between the hospital and the territory (Objective 3).

Setting and methods:

Objective1: Through the use of the e-learning modality based on the new digital technology and internet a formative syllabus will be scheduled. It will be able to identify professionals that could be case manager. Objective 2: The “Silver Code” will be improved and validated in selected hospitals in different Italian regions. The sample of the study will be represented by the hospitalized older people (more than 65 years). Objective 3: People that are more than 70 and that profit by “Assistenza Domiciliare Integrata” in the ASL of the involved regions will be enrolled. A specific form to gain information about structural features of territorial services in different experimental places. All patients will be valuated at the beginning and after one year with the multidimensional valuation form “inter RAI home care” and with the multidimensional valuation form already present in that District.

Disciplines and institutions addressed:

Università Cattolica del Sacro Cuore – Centro Medicina dell’Invecchiamento – Roma Regione Veneto Regione Toscana Regione Lazio Regione Sicilia

Funding scheme and procedure:

Risorse 1° anno (totale euro) Personale 125.000 Beni e servizi 100.000 Missioni 100.000 Spese generali 25.000 Formazione 150.000

Key topics for inclusion of foreign partners:

Remarks:

Organisation:

Department:
Centro Medicina Dell’Invecchiamento

First Name:
Roberto

Surname:
Bernabei

Title:

Function:

Address:

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Web: