緩和ケアと医学

抽象的な

New Frontiers of People-Centered Integrated Care for Complex Chronic Disease

Stellato K, Radini D, Pellizzari M, Pordenon M, Pletti L, Humar F, Apuzzo M and Di Lenarda A

Objective: Heart failure is a chronic, progressive clinical syndrome with an unpredictable trajectory and difficult prognosis. In 2012, the Italian region of Friuli-Venezia Giulia was appointed pilot leader of a European-funded project for ICT-supported integrated care addressed to European frail citizens, to test the viability and evaluate the impact of health and social care integrated services through an extensive deployment program involving 23 European regions. Methods: Cohort, prospective, randomized study with 1:1 intervention vs. usual care ratio (200 total users) Medical sensor devices and environmental sensors all contribute to keeping end-users safely at home. Integrated, real-time access to the platform allows for integration of clinical and social data. Help-desk and Contact Centre staff, provide 24/7 monitoring of alarms, as well as support to adherence and social inclusion. Results: The European project is planned to end as of December 31st, 2015. While final results are pending, focus groups, case studies and qualitative interviews show that Smart Care integrated platform is being perceived as possibly facilitating person-centred supportive care by streamlining services, allowing for updated information sharing, and providing empowerment to patients, families and professionals alike. Comments and conclusion: Integrated ICT-supported care may successfully complement chronic care pathways for complex cardiac patients. However, in-depth quanti/qualitative data analysis will have to be carried out to understand whether the benefits in terms of work overload and economic costs are such as to allow for costly technical and organizational choices. Supportive pathways need to build on actual integrated team work experience and leadership. GPs’ roles, responsibilities and economic incentives need to be clearly defined in order to make integration viable and sustainable in the long run. Nurses may play an important role in the coordination and monitoring of services but workloads and responsibilities require clear definition and assessment. Training and education need to be carefully planned and steadily monitored to maintain retention and support stakeholders’ empowerment. Integrated ICT-supported care should always be utilized within a beehive-integrated person-centred model to enhance the quality of IT-supported health and social care interventions which cannot and should not replace personal and social interactions.