Orthogeriatric Projects. The integrated care pathway. Salvatore Ferro, MD Department Hospital Services Emilia-Romagna Region Health Authority

Dimensione: px

Iniziare la visualizzazioe della pagina:

Download "Orthogeriatric Projects. The integrated care pathway. Salvatore Ferro, MD Department Hospital Services Emilia-Romagna Region Health Authority"

Mauro Paolo Valentini
7 anni fa
Visualizzazioni

1 Orthogeriatric Projects The integrated care pathway for elderly hip fracture patients in the Region Salvatore Ferro, MD Department Hospital Services Region Health Authority Bologna, November 25 th 2010 Key Words Hip Fracture Age, Sex, Frail Disability Social and Health Care Problems Appropriate Care Resourses Health Care Organisation Health Services Research 1

2 Over 75 = 11,4 % - Over 80 = 6,9% 13% increase Contents Regional Health Policy (PSSR ) 2010) Planning Health Organisation Key Point for Implementation Implementation phase in all Health Boards Definition of Objectives for Health Boards Define clinical-organisational indicators to measure the level of implementation of Orthogeriatric Care in the regional health boards Monitoring and Outcome evaluation 2

3 Orthogeriatic Care Proof of effectiveness 1. Scottish Intercollegiate Guidelines Network. Management of Hip Fracture in Older People: A National Clinical Guideline. Guideline 111. SIGN, Edinburgh Australian Guidelines ; Mak et al. Evidence-based guidelines for the management of hip fractures in older persons: an update. Med J Aust. 2010;192(1): United Kingdom National Institute of Clinical Excellence (NICE) draft Guidelines The Management of Hip Fracture in Adults (October 2010). In general suboptimal care and/or fragmentation of care result in longer periods of dependency and/or hospitalisation leading to greater cost as well as inferior outcomes (NICE) PSSR PERCORSI ASSISTENZIALI INTEGRATI Obiettivo: - Garantire continuità delle cure e soddisfacimento di bisogni eterogenei attraverso lo sviluppo, la qualificazione e specializzazione della rete dei servizi, valorizzando e sostenendo il ruolo delle famiglie e privilegiando quale sede di elezione il domicilio; Azioni: - Gestione Integrata del Paziente (presa in carico e continuità delle cure); - Identificazione di Equipe di Professionisti (assistenza integrata e personalizzata) con la Famiglia o i Care-Givers quali componenti dell equipe curante; - Attuazione di un Piano Individuale - Definizione di un Coordinamento che assicuri la continuità assistenziale; - Adeguatezza degli interventi e valutazione di efficacia del percorso di cura. 3

4 PSSR Anziani Over 75 = 11,4 % - Over 80 = 6,9% - Prevalenza di M. Cronico-Degenerative Azioni sociali e sanitarie ---- prevenire la disabilità; migliore gradimento e rapporto costo-efficacia delle soluzioni assistenziali Obiettivi e Azioni: Informazione, Accesso, Relazioni e Comunicazione Assicurare la Promozione della Salute e la Prevenzione dalla Disabilità Sviluppare la Domiciliarità, Valorizzare il Lavoro di Cura e Sostenere le Famiglie Orthogeriatric Care Project Phases PRI ER seminar Appropriate care for elderly hip fracture patients 26 November Establishment of a Multidisciplinary Working Group - Specialists: Geriatricians, Orthopaedics, Physiatricians, Internists, Ambulance and emergency physician; Radiologist, Anesthesiologist, Physician-Nutrition, General Practitioner; - Organisational doctors: Health Directors, Hospital Managers and Primary Care Department Directors; - Nursing Service Managers, Nurses, Physiotherapists - Social Service Staff (Health boards and Municipalities); - Regional Health Authority and Health and Social Agency staff 4

5 1. PREVENTION PHASE - Early recognition of the event Prevention of falls Regional Planning Document Key points for implementation 2. PRE-HOSPITAL - ACUTE AND POST-ACUTE HOSPITAL PHASE - Trasfer to hospital as quick as possible - Emergency Department management; - Diagnostic investigation Timing of Surgery Prophylaxis against infections - Anaesthetic and Surgery management Early post-operative management - Dedicated unit in the hospital multidisciplinary team Early mobilisation; - Rehabilitation and Discharge ; 3. ORGANISED CARE CONTINUITY PATH - Identification of hospital and health care district case-managers for care continuity - Assessment of socio-sanitary needs of elderly hip fracture patients - Preparation of the patient discharge planning Hip Fracture Monitoring 5

6 Elderly Hip Fracture Path phases to monitoring acute post-acute community Early surgery Clinical factors Organizational factors 2. Early mobilisation 1. Controll and monitoring: Surgery complications symtoms (pain, pressure damage, cognitive disfunctions) 2. rehabilitation 1. Care continuity (GP, home care, rehabilitation) Social care Outcome evaluation: mortality disability quality of life Integrated Health Information System Emilia Romagna Region Web Site Hospital Discharges data Ambulatory care data Drugs data consumes Regional Mortality data 6

7 Elderly Hip Fracture Patients N = Sesso N. casi Età Media Mediana Femmine ,45 84 Maschi ,42 83 % casi per sesso e classi di età - Anno ,8 76,2 78,9 80,6 60 % ,2 23,8 21,1 19, anni anni anni 95 anni e più Femmine Maschi Local Health Unit % Surgery < 2days in 65 + Monitoring process and outcome indicators Process and Outcome Indicators in hip fracture patients (aged 65+) - Year Region % Hospital Rehabilitation % Hospital % Ambulatory Longterm Care Rehabilitation Crude Mortality Rate PIACENZA 63,3% 12,4% 61,9% 2,4% 5,1% PARMA 43,8% - 54,7% 1,4% 3,4% REGGIO EMILIA 35,9% - 42,1% 2,1% 5,5% MODENA 44,1% 8,8% 56,2% 1,2% 4,9% BOLOGNA 30,2% 6,2% 58,5% 6,8% 6,0% IMOLA 38,8% - 62,8% 1,6% 5,2% FERRARA 23,2% - 73,0% 3,8% 3,4% RAVENNA 50,5% 0,7% 44,0% 5,8% 3,6% FORLÌ 70,4% - 91,8% 0,4% 7,0% CESENA 34,5% - 16,4% 11,2% 5,6% RIMINI 29,1% 1,0% 49,5% 1,8% 3,7% AOSPU PARMA 60,5% 11,9% 61,7% 3,9% 5,6% AOSP REGGIO EMILIA 40,2% - 56,3% 1,2% 9,0% AOSPU MODENA 16,8% - 69,7% 2,0% 3,0% AOSPU BOLOGNA 56,5% 25,3% 61,0% 3,0% 3,7% AOSPU FERRARA 13,7% 7,1% 83,1% 2,4% 8,2% I.O.R. 58,9% 14,0% - 5,8% 4,7% Total 44,0% 7,9% 57,5% 3,6% 5,1% 7

8 8

Documenti analoghi

53 Congresso Nazionale SIGG Firenze, Novembre L ORTOGERIATRIA: MODALITA DI ATTUAZIONE E RISULTATI Descrizione di Esperienze in varie Sedi

53 Congresso Nazionale SIGG Firenze, 26-29 Novembre 2008 L ORTOGERIATRIA: MODALITA DI ATTUAZIONE E RISULTATI Descrizione di Esperienze in varie Sedi Giorgio Annoni Cattedra e Scuola di Specializzazione