CONTINUITY AND COOPERATION IN HEALTH CONTINUITY AND COOPERATION IN HEALTH CARE SERVICESCARE SERVICES - - HPH Standard 5HPH Standard 5

Since the establishment of the Piedmont Region HPH Network in 1998 the continuity of care between hospitals and local health services has been the main task for all the participants hospitals with the aim of improving the integration between different sectors of healthcare in Piedmont.Attention has been paid to communication between health operators at admission and discharge of patients through the dissemination and evaluation of questionnaires, that showed that integration was rather poor and often completely disregarded in most of the 22 regional healthcare agencies.Starting from this previous experience our group, including 18 of the 22 presently existing healthcare agencies in Piedmont, define standards including a number of measurable indicators. The aim for the next four years is to improve the quality of life for all patients with special attention to the most ‘’fragile’’ groups (elderly, socially disadvantaged, chronic diseases) through the adoption of self assessment procedure by all the health operators involved, and the continuous assessment of patient satisfaction.

‘’Integrated Healthcare Services’’ Group Piedmont Region HPH NetworkMaria Grazia De Rosa°, Giorgio Avataneo$, Carla Bena*, Donatella Benetazzo^, Lorenzo Brusa°°, Claudia ContrattoX, Antonello Culotta**, Maurizio Gionco^^, Massimo Leporati+, Patrizia Martinoli++, Pierangelo Narettox, Liliana Pala^^, Walter Peiretti°, Caterina Pitisanoç, Carlo Prastaro^, Gisella Revigliono*, Chiara Maria Rossixx, Paola Sderci**, Paola Sguazzi$$, Maria Rosa SicuranzaZZ, Anna Toselli°, Marisa TosoZ, Marilena ValleroZZ, Paola ZarinoZZ, Angelo Penna^

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Poster n. 103

HPH Standard 5Continuity and cooperation

The organization has a planned approach to collaboration with other health service levels and other institutions and sectors on an ongoing basis.To ensure collaboration with relevant providers and to initiate partnerships to optimise the integration of health promotion activities in patient pathways.

Objective:

• The organization ensures that health promotion services are coherent with current provisions and health plans.• The organization identifies and cooperates with existing health and social care providers and related organizations and groups in the community• The organization ensures the availability and implementation of activities and procedures after patient discharge during the post-hospitalisation period• The organization ensures that documentation and patient information is communicated to the relevant recipient/follow-up partners in patient care and rehabilitation

Standards for Health Promotion in HospitalsWHO European Office for Integrated Health Care Services

As part of welfare activities, the organization may facilitate the promotion of health through more informed care pathways, improving accessibility to services and continuity of care. These objectives can be achieved by implementing information and education, leading to greater availability of services for patients, caregivers and health professionals.

Patients with social and health problems require high levels of organization, in this situation, the promotion of health is not a secondary objective. The methodology used, through training and information, reduces stress and provides support to patients, families and healthcare professionals. Developing health-promoting actions requires assessment of different aspects, that working group will analyze, as shown in the box below

Standards and indicators for patients care with chronic disease

The ‘’Integrated Healthcare Services’’ Group - Piedmont Region HPH Network is proposing to consolidate and implement the standard HPH N. 5: CONTINUITY 'AND COOPERATION. In particular, the aim is to improve the organizational integration of services to support specific pathways of care for patients with greater complexity. Previous research assessed in Piedmont health service, regarding adherence to the standards set in the document ''Discharge from hospital: pathway, process and practice’’ - Department of Health 2003 UK. The analysis conducted in 2005 on health services, by self-assessment questionnaire, has revealed an heterogeneous situation characterized by a weak capacity to ensure planning of discharge. The Working Group for 2009-2010 proposes a revision of standards listed in the questionnaire (Discharge planning self-assessment tool) with the aim of developing appropriate standards for each process indicators, outcome etc., easy and reproducible measurement. The study will be collected specific projects have already been made in Piedmont, related to the standards identifiedThe requirements relate to the following topics:

- Policy of discharge - Human resources, training - Protocols and planning - Documentation, laws and regulations - Communication - Verification and quality control - Search

Definition of arguments is necessary to collection documents and other material, with the aim of creating a specifically site to the project on HPH CIPES portal.

Contributions up to date presented by participants refer to the following topics: training, communication, care and discharge planning.

Tratto da www.wikipedia.it

mariagrazia.derosa@asl17.it