Assessing the engagement in a post-discharge phone Follow-Up project

Abstract

Introduction: The article describes a post-discharge telephone Follow-Up pilot project that was activated in 2018 in the city of Trieste.
 Methods: The pilot project, in addition to the interception of possible situations of discomfort to be reported to social services and to ensure informative support to guide people to an optimal use of services, aimed to investigate the conditions, 1 and 3 months after discharge, of people not followed by the community services, in particular: a) maintenance of functional capacity; b) self-assessment of the patient with respect to health conditions and level of engagement; c) state of the relationships network; d) use of public, private and/or third sector health or welfare resources.
 Results and Conclusions: The Telephone Follow-Up has made it possible to experiment a “light” way of taking care of people discharged from a hospital or rehabilitation facility, to intercept situations of discomfort, reporting them to the Local District and social services and facilitating the appropriate use of local assistance services.