Continuità assistenziale: modelli e pilastri [Pitch]

[Autom. eng. transl.] Continuity of care is defined as a set of actions aimed at ensuring the transition between different levels of care. The increasing age of the population and the prevalence of chronic diseases require strategies and programs that allow patients to safely face the difficulties of hospitalization, post-acute care and the transition between the two levels. The transition to care in a fragmented system of care can compromise patients' health status. The aim of this study is to analyze the models of continuity of care and international approaches to the continuum of care by identifying their main pillars. For the research, a narrative review of the scientific literature was performed, within the Pubmed database, using the free text terms: chronic disease, continuum of care, primary care, secondary care, care models. Only the systematic reviews in Italian and English were included in the study, focusing on the application of models of care continuum, with particular reference to the areas of chronicity, comorbidity, disability or frailty. The initial search identified 129 studies. After reading the title and abstract, 33 articles were selected; after that of the full-text, 22 publications were chosen. The review revealed 9 models of continuity of care, among which the most described is the '' integrated care model '', which aims at better coordination between primary and secondary care. The study highlighted pillars common to the models analyzed: patient involvement and empowerment (86% of the studies), multidisciplinarity (73% of the studies), care coordination (50% of the studies), case management (50% of the studies), integration health and social care, patient centrality, digital health, doctor-patient relationship and communication. The continuum of care is a key aspect of an integrated system aimed at guiding the patient along his care path. The pillars of the continuum of care are interdependent and part of a process designed to respond on multiple levels to the complex needs of the chronic and multimorbid patient. In fact, the research suggests that the orientation of the delivery system towards primary health care, with particular attention to the centrality of the patient and the multidisciplinary and integrated approach to assistance, are necessary to meet the multiple health needs of the chronic patient and improve the treatment path.