Continuity of care in surgery: the module planning
© Ferrocci et al; licensee BioMed Central Ltd. 2010
Published: 19 May 2010
In recent decades in Italy, there has been a progressive aging of the population with a consequent increase in chronic degenerative diseases which has caused a substantial increase in demand for long-lasting social-health performance for patients with different degrees of disability and low self-sufficiency levels . Comorbidity is therefore becoming the most common clinical situation for the geriatric population and very often these patients require surgery.
Materials and methods
The geriatric surgical patient may complicate not only the surgery but also the postoperative. Moreover, the many associated comorbidities may be reaggraveted not only by the surgery, but also by the drugs and the hospitalization. Hence the consequence is the need of prolonged care in time and a diverse social-medical intervention also action to improve the quality of life. A radical innovation in this direction is represented by the "chronic care model". This methodology based on cooperation between surgeon and geriatrician and is based on three elements: the multidimensional assessment (VMD), the continuity of care (AC), and a multiprofessional team (UVGO) able to ensure continuity of care according to the patient’ needs.
For about ten years, new care models have been tested engaging different professionals designed to facilitate communication between the hospital care and the district assistance. These competences have produced evidence of the improvement of the functional outcomes and of the patients quality of life with the same costs and without increasing mortality .
The demographic changes taking place are to have a strong impact on the composition of the Italian population, in which the elderly bearers of chronic diseases are considerably increasing. The traditional model of care does not appear adequate to ensure the best results in terms of maintaining skills and quality of life and helps to make the overall system of care barely sustainable from an economic perspective. In literature new management models were proposed dedicated to the care of chronicity, keeping as their main objective the welfare of the elderly patient, understood in terms of the maintenance of residual autonomy and the reduction of costs .
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