[Continuing care: experimental project of integration from San Camillo Forlanini Hospital and Local Health Unit in...

The continuity care process tip to realize a rationalization of the distance of the patient from the acute phase, to the acute phase subintensive care area and in the territorial care. In this last phase, the project proposed to implement the experimentation through the determining role of the nursing profession and health care professions. These professions will carry out the function hinge between the truth hospital worker and that territorial one. In extreme synthesis continuity manager (the nurses of the continuity care) and the houses manager (nurses/technical of the rehabilitation case manager) will be the guarantors of the continuity care accompanying the patient from the bed of the hospital to the house seat. Such plan, besides to reduce the ungluing between hospital and territory, being realized a sure distance in the phase of rehabilitation of the subject, determines also the reduction of the improper resource to the hospital. In fact, the territorial actors, in time activated will be in a position to answering timely to the eventual emergent necessities or better to prevent them. Moreover, also through the active involvement in the plan of the General Medicine Doctors, they improve the collaboration and integration between the various professionalities been involved through a continuous and structured communication and the sharing of the health care distances.