The Chronic Related Groups Program: A Case Study

The Chronic Related Groups Program: A Case Study

Marco Nalin (Telbios, Italy), Ilaria Baroni (Telbios, Italy) and Maria Romano (Telbios, Italy)
Copyright: © 2016 |Pages: 10
DOI: 10.4018/978-1-4666-9978-6.ch003
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Background

Lombardy (Lombardia, capital: Milan) is one of the 20 regions in Italy. In 2007, 9.545.441 people lived in Lombardy, with about 19.7% of its population above 65 years of age and about 27.5% being diagnosed with a chronic condition. Lombardy is divided into 12 administrative provinces. In 1997, Lombardy was the first Italian region with the setting of a so-called quasi-market model in its local health care system (Melchiorre et al., 2013); it has introduced competition to improve quality and control expenditures. As a consequence, the four main principles of the Lombardy health care system are universal coverage (solidarity), a separation between health care purchasers and providers, a competition between public and private accredited providers in the presence of a third part payer and patients’ free choice among providers.

The health system is financed by general taxation and by citizens outpatient services co-payment. The National Government assign the financial resources to the Regions on a capitation system, adjusted for different indicators (age, chronic diseases, geomorphology etc..)

Key Terms in this Chapter

Telemonitoring System: System to measure vital signs remotely, and to manage escalation strategies based on pre-determined rules applied on the measured data.

Stratification Tools: Stratification tools identify complex frail and high risk patients and maintain these patients on the radar of the Health Services. They help ensuring appropriate coverage of key secondary prevention interventions and processes, including managing disease registers systematically by modelling expected versus actual prevalence and incidence, and thereby identifying practices where improvement is necessary.

Care Plan: The Care Plan is a one year planning of all the health related activities that the patient will do to manage his disease and co-morbidities, including GPs’ visits, specialists’ visits, lab exams, vital signs monitoring (e.g., ECG), etc.

GP: General Practitioner, often referred to also as Family Doctor.

Frailty: Frailty is a common geriatric syndrome that embodies an elevated risk of catastrophic declines in health and function among older adults.

EHR: Electronic Healthcare Record.

Care Coordination: A systematic and holistic approach which includes coordination in the management of care for (chronic) patients, which might be affected by multiple pathologies and should then be managed with a unified approach, rather than a fragmented one typical of most healthcare systems.

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