Integrazione Ospedale-Territorio: programmazione e implementazione di percorsi specifici di promozione della continuità assistenziale

Introduction The integration between hospital facilities and territorial services represents one of the most significant and urgent challenges in the contemporary healthcare landscape. The hospital discharge process and its accurate planning are crucial steps to ensure continuity of care. The aim of the study was to assess the level of organizational appropriateness of an internal medicine ward by analyzing “outlier” admissions using the PRUO method, in order to identify critical issues and propose specific strategies to reduce organizational inappropriateness and the length of hospital stays. Methods The study was divided into four phases: • Descriptive Phase aimed at understanding the existing healthcare offerings at the territorial level and the request for territorial assistance by the investigated ward; • Evaluation Phase 1 of the organizational appropriateness of ordinary hospital stay activities (2018-2019); • Intermediate Operational Phase in which, based on the data analyzed in the previous phases, the adoption of systems to prevent difficult discharges was proposed; • Evaluation Phase 2 of the results obtained (2020-2022). Results In the initial evaluation phase, 44% of the hospital stays fully met the appropriateness criteria for the entire period of hospitalization. The main reasons for inappropriateness included delays in transferring to lower complexity care facilities and delays in performing diagnostic tests. Similarly, there was a lack of involvement of the corporate social worker and an inadequate perception of the importance of correct SDO coding (V codes). Based on the overall outlined framework and considering the information that emerged from the analysis, the adoption of the BRASS assessment tool was suggested. In the subsequent evaluation, 43.1% of the hospital stays fully met the appropriateness criteria, and a significant reduction in the difficulties of patient discharge to other care settings was noted, hopefully also due to the corrective interventions adopted. At the same time, greater difficulties emerged from the diagnostic services in promptly responding to the needs of the wards. Conclusions The discharge process must be interpreted not as a circumscribed episode but rather as a process that begins with the patient's admission to the hospital and extends throughout the hospital stay. In fact, the discharge path often lacks proactive planning and is characterized by a series of interruptions and fragmentations in care, which expose patients to significant risks such as complications after discharge or the need for new hospitalizations in a short time.