Abstract
The world of chronicity is an area in progressive growth that involves a considerable commitment of resources, requiring continuity of assistance for long periods of time and a strong integration of health services with social ones and those requiring residential and territorial services often not sufficiently designed and developed. The fundamental aim of the treatment of chronic systems is to keep as much as possible the patient at home and prevent or reduce the risk of institutionalization. GP could put their expertise to good use in the Complex of Primary Care Units and Territorial Functional Aggregations, reducing the costs of the health service.
Highlights
The world of chronicity is an area in progressive growth that involves a considerable commitment of resources, requiring continuity of assistance for long periods of time and a strong integration of health services with social ones and those requiring residential and territorial services often not sufficiently designed and developed
About 30% of those are dedicated to people with serious chronic diseases [4]
GPs in question could put their expertise to good use in the Complex of Primary Care Units and Territorial Functional Aggregations, reducing the costs of the health service
Summary
The world of chronicity is an area in progressive growth that involves a considerable commitment of resources, requiring continuity of assistance for long periods of time and a strong integration of health services with social ones and those requiring residential and territorial services often not sufficiently designed and developed. Hospital should be conceived as a highly specialized hub of the chronic care system, which interacts with the outpatient specialist and with primary care, through new organizational formulas that provide for the creation of dedicated multi-specialist networks and "assisted discharge " in the territory, aimed at reducing the drop-out from the service network, a common cause of re-hospitalization and short-term adverse outcomes in patients with chronicity. The patient's journey with chronic disease should be planned in the long run and managed proactively and differentiated to respond effectively and efficiently to specific needs It must prevent the occurrence of avoidable complications and be shared and managed by a team consisting of different figures (GP as coordinator, Nurse, territorial and hospital specialist, social worker, etc.) in a logic of cooperation and shared responsibility [11]. The change in care models for chronicity confirms the need for an ever closer relationship between primary and specialist care; a new figure of general practitioner who integrates his role as generalist with the knowledge of a disciplinary area, not so advanced and profound as to match that of the specialist (to whom this figure does not intend to replace), but such as to face the problem of the patient with greater competence and offer an additional high quality service [12]
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