Abstract
The monitoring of elderly people with dementia: a "primary care" model of the Local Authority for Health of Modena
Highlights
In the province of Modena an agreement between the Local Authority for Health (Azienda Sanitaria Locale, ASL) of Modena and the General Practioners (GPs) is in force since 2002
The categorisation of dementia severity based on the MMSE scores highlights some inconsistency
35.6% of the patients with MCI show a MMSE score
Summary
In the province of Modena an agreement between the Local Authority for Health (Azienda Sanitaria Locale, ASL) of Modena and the General Practioners (GPs) is in force since 2002. It consists of a protocol for integrated care of people with dementia (PWD) and their families between GPs and the Specialist centres for cognitive disorders, divided into two stages: 1) Taking charge of the patient by the GP (module A) ; 2) Follow-up care management, with annual reporting by the GP to the ASL by means of a pre-set paper module (module B) containing besides patients’ demographic characteristics, clinical and therapeutic data. The objective of this project is to monitor the condition of both the patient and the family in order to promptly alert the social services and the network of integrated health and social services in the attempt to delay and/or prevent hospitalisations and/or inappropriate institutionalisation of PWD
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